BlueCare SM. Member Handbook. A Guide to Your Health Plan

Transcription

1 BlueCare SM 2014 Member Handbook A Guide to Your Health Plan

2 (inside front cover) FREE Phone Numbers to call for help BlueCare call about your health care BlueCare CHOICES in Long-Term Services and Support call to apply for CHOICES or to speak to your Care Coordinator Nurse Help Line DentaQuest call about dental (teeth) care for children under age 21 TennCare Pharmacy Program call about TennCare pharmacy services Tennessee Health Connection call about: change of address, job, or income, TennCare co-pays, appeals to get or keep TennCare, applying for TennCare, programs like Food Stamps or Families First TennCare Advocacy Program call for help with physical health services or for help with Behavioral Health Services (mental health, alcohol, and drug abuse services) TennCare Solutions Unit call about problems getting health care or to file a medical appeal Medicare Information and Assistance Line call about Medicare SHIP Help Line call for help with Medicare Social Security Administration call about Social Security and Disability Office of Inspector General (OIG) call to report TennCare fraud or abuse Transportation Services call for a ride to get health care if you don t have a way to get there TTY/TDD Line: TTY/TDD Line: (East) Or (West)

3 Doctors Names Phone Numbers 1

4 TennCare and your health plan, BlueCare Member Handbook 2014 Necesita un manual de TennCare en español? Para conseguir un manual en español, llame a BlueCare al Your Right to Privacy There are laws that protect your privacy. They say we can t tell others certain facts about you. Read more about your privacy rights in Part 7 of this handbook. Important! Even if you don t use your TennCare, the state still pays for you to have it. If you don t need your TennCare anymore, please call the Tennessee Health Connection for free at We do not allow unfair treatment in TennCare. No one is treated in a different way because of race, color, birthplace, religion, language, sex, age, or disability. Read more about your right to fair treatment in Part 7 of this handbook. 1

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6 Table of Contents Welcome to TennCare and your health plan, BlueCare 6 BlueCare 6 Your other health plans 7 Part 1: Using your TennCare health plan 9 BlueCare provider network 10 Language help at your visits 10 Rides to your visits 11 Doctor visits 11 Changing your PCP (doctor) 12 Behavioral Health (Mental health, alcohol, and drug abuse 13 services) Specialist providers 15 Hospital care 15 Emergencies for physical health 15 Emergencies for mental health 17 Part 2: Services that TennCare pays for 20 Benefit packages: covered services 20 Care with limits 31 Other TennCare services 35 Preventive care to keep you well 38 Preventive care for adults 38 Women s health and pregnancy 38 After your baby is born 39 Preventive care for children: TENNderCARE Health care for 40 your child or teen Dental care for children 42 Non-covered services 43 Part 3: TennCare CHOICES in Long Term Services and Supports (LTSS) Program 45 What is it and how to apply 45 Long Term Services and Supports 48 Care Coordination 51 Paying for CHOICES 57 Disenrollment from CHOICES 60 3

7 Table of Contents, continued Part 4: How the TennCare program works for you 63 What you pay for your health care Co-pays 63 How TennCare, Medicare, and other insurance work together 67 Part 5: Help for problems with your health care or TennCare 70 Kinds of problems and what you can do 70 Need a new TennCare card? 70 Need to find a doctor or change your doctor? 70 Need to make a complaint about your care? 70 Need help with rides to health care visits? 70 Need to change your health plan, or BlueCare? 70 Need help getting prescription medicine? 72 Need help getting your health care services? 74 Are you getting billed? Did you have to pay? 74 Ways that your TennCare can end 75 Part 6: TennCare Appeals 76 Medical Appeals - How to appeal health care problems 76 How to appeal problems getting or keeping TennCare 77 Part 7: Your rights and responsibilities 80 Your rights and responsibilities as a TennCare and BlueCare 80 member Your right to fair treatment 80 Your right to privacy 80 Your health information rights 80 Your responsibility to report fraud and abuse 81 Your right to appeal health care problems 84 Your right to a fair hearing 86 Part 8: Health care papers you may need 92 PCP (Doctor) change request 93 Unfair treatment complaint 96 Medical appeal 99 Advance directives 101 4

8 Part 9: More Information 105 TENNderCARE: Children and teen 107 immunization schedule Legal definitions 108 5

9 Welcome to TennCare and your health plan, BlueCare This is your TennCare member handbook. This handbook tells you how to use your TennCare to get care. TennCare is Tennessee s program for health care. It works like health insurance to help pay for many health care services. There are two kinds of TennCare: TennCare Medicaid and TennCare Standard. You have either TennCare Medicaid or TennCare Standard. The difference is in the way that you got your TennCare. TennCare Medicaid is the kind of TennCare that most people have. The rules for TennCare Medicaid say your income and sometimes your resources have to be looked at. Resources are things that you own or money you have saved. You also have to be in a certain group, like children under age 21 or pregnant women. In Tennessee, people who get SSI (Supplemental Security Income) benefits get TennCare Medicaid too. You can apply for SSI benefits at the Social Security office. Some people have TennCare Medicaid and other insurance. Most of the time, that s ok. The federal government says you can have Medicaid and other insurance as long as you meet the rules for Medicaid. Do you have TennCare Medicaid because you are enrolled in the Breast and/or Cervical Cancer Program? Then you can t have other insurance, including Medicare, if the insurance covers treatment for breast and/or cervical cancer. TennCare Standard is the second kind of TennCare. Only certain people qualify for TennCare Standard. TennCare Standard is for children under age 19 who are losing their TennCare Medicaid. When it was time to see if they could keep TennCare Medicaid, they weren t eligible. But, the TennCare Standard rules say that these children can move to TennCare Standard if they don t have access to group health insurance. Sometimes they must have a health condition, too. Having access to other insurance, even Medicare, is not allowed for children who have TennCare Standard. There is another kind of TennCare Standard for adults age 21 and older called TennCare Standard Spend Down (SSD). It s called Spend Down because to qualify, you use medical bills to spend down (or lower) your income. Adults can only apply during certain times of the year and must meet other rules too. It s ok to have SSD and other insurance, like Medicare, as long as you meet the rules. Why is it important to know the kind of TennCare you have? Because it helps you know about the kind of TennCare benefits you have. It also helps you know if you must pay co-pays for TennCare services. We ll tell you more about your TennCare benefits and co-pays later in this handbook. 6

10 TennCare sent you a letter to tell you that you have TennCare and what day your TennCare started. If you have questions or problems about your TennCare dates, you can call the Tennessee Health Connection for free at Important! State law says you must tell TennCare about any changes that may affect your coverage. You must report these changes within 10 days of the change. And, you must give TennCare the proof they need to make the change. Call the Tennessee Health Connection right away if: You move** You change jobs. The number of people in your family changes. Your income changes. You get or can get group health insurance. **Anytime you move, you must tell TennCare about your new address. Why? TennCare sends you important information about your TennCare coverage and benefits in the mail. If they don t have your current address, you could lose your TennCare. Call the Tennessee Health Connection at to tell TennCare about your new address. Do you get SSI checks from the Social Security Administration (SSA)? Then you must call your local SSA office and give them your new address. After you call the Tennessee Health Connection or Social Security, call us at and tell us your new address too. Your TennCare Health Plans BlueCare is your TennCare health plan that helps you get physical or behavioral health care (mental health, alcohol and drug abuse services). We re sometimes called your Managed Care Organization, or BlueCare. For questions about getting physical or behavioral health care, call us at It s a free call. Do you have questions about your health? Do you need to know what kind of doctor you should see? Call our Nurse Help Line at It s a free call. Do you need to change your health plan? Is BlueCare the health plan that you asked for? If you need or want to change your health plan, you have 45 days from the day you got your TennCare letter. To change your health plan in the first 45 days, call the TennCare Solutions Unit at for free. Tell them you just got your TennCare and you want to change your health plan. After 45 days, it s harder to change your health plan. Part 5 of this handbook tells you more about changing your health plan after your first 45 days. Do you want to change health plans because you re having problems getting health care or can t find a doctor? Call us at for free. We ll help you fix the problem. You don t have to change health plans to get the care you need. 7

11 Do you want to change health plans so you can see a doctor that takes a different health plan? First, be sure that all of your doctors will take your new health plan. You ll only be able to see doctors that take your new plan. What if you want to change your health plan but you have an OK from us for care you haven t gotten yet? If you change your health plan and still need the care, you ll have to get a new OK from your new plan. Pharmacy Health Plan If you have prescription coverage through TennCare, your prescription benefits will be provided by a Pharmacy Benefits Manager, or PBM. TennCare s pharmacy plan is called Magellan Health Services. Watch your mail for your new pharmacy card. What if you don t get your new pharmacy card soon? If you need a prescription filled, you can go to the pharmacy anyway. Tell them you have TennCare. Before you go, make sure the pharmacy you use accepts TennCare. To find out, go to Near the top of the page, click the link to find a pharmacy. Then look for Find a Pharmacy or Physician. Click Pharmacy. Enter the information requested to find pharmacies near you that accept TennCare. Or, you can call the TennCare pharmacy help desk at Do you need more help? Do you have questions about your card? Call TennCare s pharmacy help desk at Learn more about your prescription coverage in Parts 1 and 2 of this handbook. Dental Health Plan for children TennCare only covers dental care for children under the age of 21. TennCare s dental health plan is DentaQuest. They can help you if you have questions about dental care. To find a DentaQuest dentist, go to Then click Find a Dentist. Or you can call them at Note! TennCare does not cover any dental care, including oral surgery, for adults age 21 and older. Learn more about dental coverage for children under age 21 in Parts 1 and 2 of this handbook. 8

12 Part 1: Using your TennCare Health Plan Every BlueCare member has a Member card. This is what your card looks like: Member ID Group No. VER: 5.1 (PCP) Primary Care Provider Effective Date Member DOB: Benefit Level: Copayments: Providers: File all claims with local BCBS Plan. Prior Authorization is required for certain services. Benefits will not be provided for unauthorized services or for non-emergency services provided by out-of-network providers. BlueCare Tennessee Claims Service Center 1 Cameron Hill Circle Suite 0002 Chattanooga, TN bluecare.bcbst.com Member Service: Network Provider Outside Tennessee: (BLUE) Provider Service: Prior Authorization: Advanced Radiological Imaging Auth: /7 Nurseline*: *Not BlueCross BlueShield products Members: Always show this card and tell your provider to check for prior authorization. Remembe r, you get your care from your care provider (PCP), listed on the front of this card, except in emergenc y. Call your PC P within 24 hours of emergency care. This card is for identification, not for proof of eligibility. 702 (05/13) Here are some of the things that your card has on it: Member Name is the name of the person who can use this card. ID Number is the number that tells us who you are. Group Number tells us what part of Tennessee you live in. Primary Care Provider (PCP) is the person you see for your health care. Effective Date is the date that you can start seeing your PCP listed on your card. Date of Birth is your birth date. Co-pays are what you pay for each health care service. Not everyone has co-pays. Benefit Indicator is the kind of TennCare benefit package you have. Your benefit package is the kind of services or care TennCare covers for you. Carry your card with you all of the time. You ll need to show it when you go to see your doctor and when you go to the hospital. This card is only for you. Don t let anyone else use your card. If your card is lost or stolen, or if it has wrong information on it, call us at for a new card. It s a free call. If you have questions about TennCare or BlueCare, you can: Call us at or write to us at: bluecare.bcbst.com 9

13 BlueCare Providers In Network The doctors and other people and places who work with BlueCare are called the Provider Network. All of these providers are listed in our Provider Directory. You can find the Provider Directory online at bluecare.bcbst.com. Or call us at to get a list. Providers may have signed up or dropped out after the list was printed. But, the online Provider Directory is updated every week. You can also call us at to find out of a provider is in our network. To find doctors who speak other languages, you can also check the BlueCare Provider Directory. You must go to doctors who take BlueCare so TennCare will pay for your health care. But, if you also have Medicare, you don t have to use doctors who take BlueCare. You can go to any doctor that takes Medicare. To find out more about how Medicare works with TennCare see Part 4 of this handbook. Out of Network A doctor who is not in the Provider Network and doesn t take BlueCare is called an Out-of- Network provider. Most of the time if you go to a doctor who is Out-of-Network TennCare will not pay. But, sometimes, like in emergencies or to see specialists, TennCare will pay for a doctor who is Out-of-Network. Unless it s an emergency, you must have an OK first. Later in this section Specialists and Emergencies tells you more about when you can go to someone who is Out-of- Network. If you were already getting care or treatment when your TennCare started, you may be able to keep getting the care without an OK or referral. Call us at to find out how. How to get free language help at your health care visits If English is not your first language, you can ask for an interpreter when you go to get your care. This is a free service for you. Before your appointment, call us or your provider so you can get help with language services. You can also check in our online Provider Directory to find doctors who speak other languages by visiting bluecare.bcbst.com. 10

14 How to get help with a ride to your health care visits If you don t have a way to get to your health care visits, you may be able to get a ride from TennCare. You can get help with a ride: only for services covered by TennCare, and only if you don t have any other way to get there. You can have someone ride with you to your appointment if: you are a child under the age of 21 or you have a disability and need help to get the service (like someone to open doors for you, push your wheelchair, help you with reading or decision-making). If you need a ride to your appointment or have questions about having someone ride with you, call us at Try to call at least one week before your health care appointment to make sure that you can get a ride. If you change times or cancel your health care appointment, you must change or cancel your ride too. Doctor Visits Your Primary Care Provider the main person you go to for your care You will go to one main person for your health care. He or she can be a doctor, a nurse practitioner, or a physician s assistant. This person is called your Primary Care Provider, or PCP. The name of your PCP is sometimes listed on the front of your card. What if your card does not list the name of your PCP? Call us at for the name of your PCP or find out about other PCPs in our network. What if you want to change your PCP? The next page tells you how. Most PCPs have regular office hours. But, you can call your PCP anytime. If you call after regular office hours, they will tell you how to reach the doctor. If you can t talk to someone after hours, call us at If your PCP is new for you, you should get to know your PCP. Call to get an appointment with your PCP as soon as you can. This is even more important if you ve been getting care or treatment from a different doctor. We want to make sure that you keep getting the care you need. But even if you feel OK, you should call to get a check-up with your PCP. Before you go to your first appointment with your PCP: 1. Ask your past doctor to send your medical records to your PCP. This will not cost you anything. These records are yours. They will help your PCP learn about your health. 11

15 2. Call your PCP to schedule your appointment. 3. Have your BlueCare card ready when you call. 4. Say you are a BlueCare member and give them your ID number. Tell your PCP if you have any other insurance. 5. Write down your appointment date and time. If you re a new patient, the provider may ask you to come early. Write down the time they ask you to be there. 6. Make a list of questions you want to ask your PCP. List any health problems you have. 7. If you need a ride to the appointment and have no other way to get there, we can help you with a ride. Try to call at least one week before your appointment. Part 5 tells you more about getting a ride. On the day of your appointment: 1. Take all of your medicines and list of questions with you so your PCP will know how to help you. 2. Be on time for your visit. If you cannot keep your appointment, call your PCP to get a new time. 3. Take your BlueCare ID card with you. Your PCP may make a copy of it. If you have any other insurance, take that ID card with you, too. 4. Pay your co-pay if you have one. You can find out more about co-pays in Part 4. Your PCP will give you most of your health care. Your PCP can find and treat health problems early. He or she will have your medical records. Your PCP can see your whole health care picture. Your PCP keeps track of all of the care you get. Changing your PCP There are many reasons why you may need to change your PCP. You may want to see a PCP whose office is closer to you. Or your PCP may stop working with us. If your PCP stops working with BlueCare, we will send you a letter asking you to find a new PCP. If you do not find a new PCP, we will find one for you so that you can keep getting your care. To change your PCP: 1. Find a new PCP in the BlueCare network. To find a new PCP, look in our Provider Directory. Or you can go online at bluecare.bcbst.com, or call Then call the new PCP to make sure that he or she is in the BlueCare provider network. Be sure to ask if he or she is taking new patients. 3. If the new PCP is in our network and taking new patients, fill out the PCP Change Request in Part 8 and mail it back to us. Or you can call us at to tell us the name of your new PCP. Need help finding a new PCP? Call us at We ll work with you to find a new PCP who is taking new patients. If you change your PCP: 12

16 We will send you a new BlueCare card. It will have the name of your new PCP on it. The effective date on your new card is when we will start paying for visits to your new PCP. Any care that was scheduled for you by your old PCP has to be OK d again by your new PCP. So even if you got a referral to a specialist from your old PCP, you will have to get a new referral from your new PCP. What if you are changing PCPs because you changed health plans? You still have to get a new OK for your care from your new PCP. And if you are in the middle of a treatment plan, you should call your new PCP right away. Your new PCP needs to know about all of the care you have been getting. He or she can help you keep getting the care you need. Behavioral Health Care (Mental Health, Alcohol or Drug Abuse Services) You do not need to see your PCP before getting Behavioral Health services.. But, you will need to get your care from someone who is in our network. If you re getting care now, ask your provider if they take BlueCare. A Community Mental Health Agency (CMHA) is one place you can go for mental, alcohol or drug abuse services.. Most CMHAs take TennCare. Before your first visit: 1. Ask your past doctor to send your records to your new provider. They will help your provider learn about your needs. 2. Have your BlueCare card ready when you call to schedule your appointment with your new provider. 3. Say you are a BlueCare member and give your ID number. If you have any other insurance, tell them. 4. Write down your appointment date and time. If you are a new patient, the provider may ask you to come early. Write down the time they ask you to be there. 5. Make a list of questions you want to ask your provider. List any problems you have. 6. If you need a ride to the appointment and have no other way to get there, we can help you with a ride. Try to call at least one week before your visit. Page 11 tells you more about getting a ride. On the day of your appointment: 1. Take all of your medicines and list of questions with you so your provider will know how to help you. 2. Be on time for your visit. If you cannot keep your appointment, call your provider to get a new time. 3. Take your BlueCare ID card with you. Your provider may make a copy of it. If you have any other insurance, take that ID card with you, too. 4. Pay your co-pay if you have one. You can find out more about co-pays in Part 4. 13

17 If you need help finding mental health, alcohol and drug abuse services, call us at Or, if you have questions about mental health, alcohol and drug abuse services, call us at It s a free call. 14

18 Specialists A specialist is a doctor who gives care for a certain illness or part of the body. One kind of specialist is a cardiologist, who is a heart doctor. Another kind of specialist is an oncologist, who treats cancer. There are many kinds of specialists. Your PCP may send you to a specialist for care. This is called a referral. If your PCP wants you to go to a specialist, he or she will set up the appointment with the specialist for you. If the specialist is not in our Provider Network, your PCP must get an OK from us first. If you have co-pays, your co-pay is the same even if the specialist is Out-of-Network. Important! You cannot go to a specialist without your PCP s referral. We will only pay for a specialist visit if your PCP sends you. But, you do not have to see your PCP first to go to a women s health doctor for well-woman checkups. A women s health doctor is called an OB/GYN. The women s health specialist must still be in our network. More information about women s health care is in Part 2 of this handbook. And remember, you do not have to see your PCP first to see a behavioral health provider for mental health, alcohol or substance abuse services.. Hospital Care If you need hospital care, your PCP or behavioral health provider will set it up for you. You must have your PCP s OK to get hospital care. Unless it is an emergency, we will only pay for hospital care if your PCP sends you. Emergencies Physical Health Always carry your BlueCare card with you. In case of an emergency, doctors will know you have TennCare. You can get emergency health care any time you need it. Emergencies are times when there could be serious danger or damage to your health if you don t get medical care right away. See Part 9 of this handbook for a full definition of an emergency. Emergencies might be things like: Shortness of breath, not able to talk A bad cut, broken bone, or a burn Bleeding that cannot be stopped Strong chest pain that does not go away Strong stomach pain that doesn t stop Seizures that cause someone to pass out Not able to move your legs or arms A person who will not wake up Drug overdose These are usually not emergencies: Sore throat Cold or flu Lower back pain Ear ache Stomach ache Small, not deep cuts Bruise 15

19 Headache, unless it is very bad and like you ve never had before Arthritis 16

20 If you think you have an emergency, go to the nearest hospital Emergency Room (ER). In an emergency, you can go to a hospital that is not in the Provider Network. If you can t get to the ER, call 911 or your local ambulance service. If you are not sure if it s an emergency, call your PCP. You can call your PCP anytime. Your PCP can help you get emergency care if you need it. If you need emergency care, you don t have to get an OK from anyone before you get emergency care. After the ER treats you for the emergency, you will also get the care the doctor says you need to keep stable. This is called post-stabilization care. After you get emergency care, you must tell your PCP. Your PCP needs to know about the emergency to help you with the follow-up care later. You must call your PCP within 24 hours of getting emergency care. Mental Health Emergencies You can get help for a behavioral health emergency anytime even if you are away from home. And you don t have to get an OK from anyone before you get emergency care. If you have a behavioral health, alcohol or drug abuse emergency, go to the nearest mental health crisis walk in center or ER right away. What if you don t know where your closest mental health crisis walk in center is? Call Mental Health Crisis Services at CRISIS-1 (or ) right away. These calls are free. Or, you can call your provider. Your provider can help you get emergency care if you need it. TennCare pays for mental health emergencies even if the doctor or hospital isn t in the Provider Network. Emergencies are times when there could be serious danger or damage to your health or someone else s if you don t get help right away. See Part 9 of this handbook for a full definition of an emergency. Emergencies might be things like: Planning to hurt yourself Thinking about hurting another person These These are are usually usually NOT not emergencies: Needing a prescription refill If you have this kind of emergency: Go to the nearest mental health crisis walk in center or ER right away or Call 911 or Call Mental Health Crisis Services for Adults at CRISIS-1 (or ). These calls are free. 17

21 Children under age 18 If you are under 18 years old or your child is under age 18 and has a behavioral health (mental health, alcohol or drug abuse) emergency: Go to the nearest ER or Call 911 or Call Mental Health Crisis Services for Children and Youth at the following numbers: Memphis Region at Rural West Tennessee at Rural Middle Tennessee at Nashville Region at Upper Cumberland Region at Knoxville Region at Southeast Tennessee at Northeast Tennessee at Youth Villages offers statewide crisis services for children under age 18. If you go to the ER, someone from Youth Villages may come help evaluate your child s need for care. If you have problems reaching someone at the number listed for your area, call We will help you. You can also call 911. These calls are free. Always carry your BlueCare card with you. In case of an emergency, doctors will know that you have TennCare. After the ER treats you for the emergency, you will also get the care that the doctor says you need to keep stable. This is called post-stabilization care. After you get emergency care, you must tell your provider. Your provider needs to know about the emergency to help you with follow-up care later. You must call your provider within 24 hours of getting emergency care. Emergency Care away from home Emergency care away from home works just like you were at home. In an emergency, you can go to a hospital that is Out-of-Network. Go to the nearest ER, or call 911. If you have a behavioral health emergency, you can call Mental Health Crisis Services for free at CRISIS-1 (or ). You must still call your PCP and health plan within 24 hours of getting the emergency care away from home. Show your BlueCare card when you get the emergency care. Ask the ER to send the bill to BlueCare. If the ER says no, ask if they will send the bill to you at home. Or if you have to pay for the care, get a receipt. When you get home, call us at and tell us you had to pay for your health care or that you have a bill for it. We will work with you and the provider to put in a claim for your care. 18

22 Important! TennCare and BlueCare will only pay for emergencies away from home that are inside the United States. We can t pay for care you get out of the country. 19

23 Part 2: Services that TennCare pays for Benefit Packages Not everyone in TennCare has the same benefits. The benefits that are covered for you depends on the group you re in. The card you received will have a Benefit Indicator on the front. It tells you what group you re in and the benefits that are covered for you based on your group. Your Benefit Indicator may be different than other members in your family. If your card does not have a Benefit Indicator on the front, you can find out what benefits you have from the charts below. Or, call us at Children under age 21 Go to pages 22 and 23 for the list of benefits groups A and H Benefit Indicator Description of Group A Child under age 21 H Child under age 21 who also has Medicare Adults age 21 and older with TennCare Medicaid Go to pages 24 and 25 for the list of benefits for groups B, E, J and L Benefit Indicator Description of Group B Over age 21 E Over age 21 and enrolled in a Home and Community Based Services (HCBS) waiver for persons with intellectual disabilities J Over age 21 and is enrolled in TennCare CHOICES Group 1 or Group 2* and does not have Medicare L Over age 21, enrolled in TennCare CHOICES Group 3* and does not have Medicare *More information about TennCare CHOICES can be found in Part 3 of this handbook. Adults age 21 and older with TennCare Medicaid and Medicare Go to pages 26, 27 and 28 for the list of benefits for groups F, G, K and M Benefit Indicator Description of Group F Over age 21 who also has Medicare G Over age 21, enrolled in a Home and Community Based Services (HCBS) waiver for persons with intellectual disabilities, and has Medicare K Over age 21, enrolled in TennCare CHOICES Group 1 or Group 2*, and has Medicare M Over age 21, enrolled in TennCare CHOICES Group 3*, and has Medicare *More information about TennCare CHOICES can be found in Part 3 of this handbook. 20

24 Adults age 21 and older with TennCare Standard Go to pages 29 and 30 for the list of benefits for groups C and D. Benefit Indicator Description of Group C Over age 21 D Over age 21 and is enrolled in Standard Spend Down The groups of services are marked A to M. You can find a list of services for each group on the next pages. Some of the services have limits. This means that TennCare will pay for only a certain amount of that care. The services that are listed as medically necessary mean that you can have those services if your doctor, health plan, and TennCare all agree that you need them. If you have questions about what your physical health or behavioral health care services are, call us at Or call the Tennessee Health Connection at

25 Benefits for Children under age 21 There are 2 different benefit packages for children under age 21. Look at your child s TennCare card to find out which benefit package your child has. All TennCare covered services must be medically necessary, as defined in the TennCare rules. The definition of medically necessary is in Part 9 of this handbook. For more information on Services and Exclusions, go to Benefit Packages A and H (Children under age 21) TennCare Services A H Chiropractic services, but. CHOICES benefits (Nursing Facility care and certain Home Nursing Facility care is Nursing Facility care is covered but for and Community Based Services, HCBS) CHOICES HCBS is Skilled Nursing Facility services. not covered CHOICES HCBS is not covered Community health clinic services, but. Dental services, but. Durable medical equipment (DME), but. Emergency air and ground ambulance, but. Early Periodic Screening Diagnosis and, but. Treatment (EPSDT for children under age 21) (TennCare Medicaid) Home health services, but. Hospice care, but. Inpatient and outpatient substance abuse, but. benefits Inpatient hospital services, but. Lab and X-ray services, but. Medical supplies, but. Mental health case management. This care is not covered by Medicare. Behavioral health crisis services (mental health, alcohol and drug abuse services). This care is not covered by Medicare. Non-emergency transportation, but. Nursing facility care (CHOICES), but. Occupational therapy, but. Organ transplant and donor procurement, but. Outpatient hospital services, but. Outpatient behavioral health services, but. (mental health, alcohol and drug abuse services) Pharmacy services, but. Physical exams and checkups, diagnostic, but. and treatment services (TennCare Standard) Physical therapy services, but. Physician services, but. Continued on next page 22

26 TennCare Services A H Private duty nursing. This care is not covered by Medicare. Psychiatric inpatient facility services, but. Psychiatric rehabilitation services. This care is not covered by Medicare. Psychiatric residential treatment services, but. Reconstructive breast surgery, but. Renal dialysis services, but. Speech therapy services, but. Vision services, but. 23

27 Benefits for adults age 21 and older There are 10 different benefit packages for adults age 21 and older who have TennCare. Look at your TennCare card to find out which benefit package you have. All TennCare covered services must be medically necessary, as defined in TennCare rules. The definition of medically necessary is in Part 9 of this handbook. For more information on Services and Exclusions, go to Benefit Packages B, E, J, and L (Adults age 21 and older with TennCare Medicaid) TennCare Services B E J L Chiropractic services Not Not Not Not Community health clinic services CHOICES benefits (Nursing Facility care Not Not For more For more and certain Home and information, see information, Community Based CHOICES in Part see CHOICES 3. in Part 3. Services, HCBS) Dental services Not Not Not Not Durable medical equipment (DME) Emergency air and ground ambulance Home health services with limits. See Care with limits starting on page 31. with limits. See Care with limits starting on page with limits. See Care with limits starting on page 31. with limits. See Care with limits starting on page 31. Hospice care Inpatient and outpatient substance abuse services Inpatient hospital services Lab and x-ray services Medical supplies Mental health case management Behavioral health crisis services (mental health, alcohol and drug abuse services) Non-emergency transportation Occupational therapy Organ transplant and donor procurement Continued on next page

28 TennCare Services B E J L Outpatient hospital services Outpatient behavioral health services (mental health, alcohol and drug abuse services) Pharmacy services with no no with limits. limit limit limits. See Care with See Care with limits starting limits starting on page 31. on page 31. Physical therapy services Physician services Private duty nursing with with with with limits. limits. limits. limits. See Care with See Care with See Care with See Care with limits starting limits starting on limits starting on limits starting on page 31. page 31. page 31. on page 31. Psychiatric inpatient facility services Psychiatric rehabilitation services Psychiatric residential treatment services Reconstructive breast surgery Renal dialysis services Speech therapy services Vision services with limits. See Care with limits starting on page 31. with limits. See Care with limits starting on page 31. with limits. See Care with limits starting on page 31. with limits. See Care with limits starting on page

29 Benefit Packages F, G, K and M (Adults with TennCare Medicaid and Medicare) TennCare Services F G K M Chiropractic services Not Medicare covers this benefit Not Medicare covers this benefit Not, Medicare covers this benefit this benefit Community health clinic services CHOICES benefits (Nursing Facility care and certain Home and Community Based Services, HCBS) Dental services Durable medical equipment (DME) Emergency air and ground ambulance Home health services Hospice care Inpatient and outpatient substance abuse services Inpatient hospital services Lab and x-ray services Medical supplies Continued on next page 26 Not Not for Skilled Nursing Facility care. For more information, see CHOICES in Part 3. Not Medicare covers limited dental benefits with limits.. See Care with limits starting on page 31. Not Medicare covers limited dental benefits with limits.. See Care with limits starting on page 31. Not Medicare covers limited dental benefits with limits.. See Care with limits starting on page 31. Not Medicare covers for Skilled Nursing Facility care. For more information, see CHOICES in Part 3. Not Medicare covers limited dental benefits with limits.. See Care with limits starting on page 31.

30 TennCare Services F G K M Mental health case management Behavioral health crisis services (mental health, alcohol and drug abuse services) Non-emergency transportation Occupational therapy Organ transplant and donor procurement Outpatient hospital services Outpatient behavioral health services (mental health, alcohol and drug abuse services) Pharmacy services Physical therapy services Physician services Private duty nursing Psychiatric inpatient facility services Psychiatric rehabilitation services Medicare does not cover this care Medicare does not cover this care Not. Available through Medicare Part D with limits. Medicare does not cover this care; See Care with limits starting on page 31. Medicare does not cover this care Medicare does not cover this care Medicare does not cover this care Not. Available through Medicare Part D with limits. Medicare does not cover this care; See Care with limits starting on page 31. Medicare does not cover this care 27 Medicare does not cover this care Medicare does not cover this care Not. Available through Medicare Part D with limits. Medicare does not cover this care; See Care with limits starting on page 31. Medicare does not cover this care Medicare does not cover this care Medicare does not cover this care Not. Available through Medicare Part D with limits Medicare does not cover this care; See Care with limits starting on page 31. Medicare does not cover this care

31 TennCare Services F G K M Continued on next page Psychiatric residential treatment services Reconstructive breast surgery Renal dialysis services Speech therapy services Vision services with limits. ; See Care with limits starting on page 31. with limits. ; See Care with limits starting on page 31. with limits. ; See Care with limits starting on page 31. with limits. ; See Care with limits starting on page

32 Benefit Packages C, and D (Adults age 21 and older with TennCare Standard) TennCare Services C D Chiropractic services Not Not Community health clinic services CHOICES benefits (Nursing Facility care Not Not and certain Home and Community Based Services, HCBS) Dental services Not Not Durable medical equipment (DME) Emergency air and ground ambulance Home health services with limits. See Care with limits starting on page 31. with limits. See Care with limits starting on page 31. Hospice care Inpatient and outpatient substance abuse services Inpatient hospital services Lab and x-ray services Medical supplies Mental health case management Behavioral health crisis services (mental health, alcohol and drug abuse services) Non-emergency transportation Occupational therapy Organ transplant and donor procurement Outpatient hospital services Outpatient behavioral health services (mental health, alcohol and drug abuse services) Pharmacy services Not with limits. See Care with limits starting on page 31. Physical therapy services Physician services Private duty nursing with limits. See Care with limits starting on page 31. Psychiatric inpatient facility services Psychiatric rehabilitation services Psychiatric residential treatment services Reconstructive breast surgery Renal dialysis services Speech therapy services Vision services with limits. See Care with limits 29 with limits. See Care with limits starting on page 31. with limits. See Care with limits

33 TennCare Services C D starting on page 31. starting on page

34 Care with limits Benefits for children under the age of 21 are covered as medically necessary. But, some TennCare benefits work differently for adults age 21 and older. These kinds of care and medicine have limits for adults age 21 and older: 1. Prescription Medicine 2. Trigger Point Injections 3. Medial Nerve Blocks used to diagnose the cause of back pain. 4. Epidural Injections 5. Urine Drug Screenings 6. Private Duty Nursing and Home Health Services 7. Vision Services 1. Prescription medicine Most, but not everyone on TennCare has pharmacy benefits. If you also have Medicare, there s an important message for you in the box on page 68. Children under age 21 who have pharmacy benefits through TennCare do not have a limit on the number of prescriptions TennCare will pay for each month. And adult members who are enrolled in CHOICES Group 1 or CHOICES Group 2 do not have a monthly limit on prescriptions that TennCare will pay for each month. However, most adults who have TennCare have a limit of how many prescriptions TennCare will pay for each month. TennCare Medicaid will only pay for 5 prescriptions or refills each month. And only 2 of the 5 prescriptions can be brand name medicines. That means that at least 3 must be generic. TennCare will start counting your prescriptions and refills on the first day of each month. This limit includes prescriptions for physical health care and mental health care or alcohol or drug abuse. How do I know if TennCare covers my prescription medicines? TennCare has a list of prescription medicines called a Preferred Drug List, or PDL. The PDL is a list of medicines that TennCare covers. There are brand name medicines and generic medicines on the Preferred Drug List. Most TennCare adults have co-pays for prescriptions. You can find more about co-pays in Part 4. You can get many of these medicines at your pharmacy with a prescription from your doctor. But, some of these medicines must have an OK from the TennCare Pharmacy Program before you can get them. This OK is called a Prior Authorization, or PA. Your doctor must ask for a PA for some of the medicines on the list. Sometimes your doctor can change your prescription to a medicine that doesn t need a PA. But if your doctor says you must have medicine that needs an OK, he or she must ask for a PA. What if I need more than 5 prescriptions or refills each month? There is a list of medicines that do not count against your limit. It is called the Exempt List. 31

35 It s called the Exempt List because the medicines are exempt from (they don t count) against your limit. (Drug stores call it the Auto Exemption list.) After you ve gotten 5 prescriptions or 2 brand name prescriptions in 1 month, you can still get medicines on the Exempt List. The list may change. But, TennCare and your drug store will make sure that medicines on the most current list don t count against your limit. Do you need to find out if medicine you take is on that list? Ask your doctor or drug store. To see the most current list, you can use the internet. Go to the TennCare website at Click on Exempt. Or, call the Tennessee Health Connection at Ask them to mail you a copy. There s another list of medicines that can help you with your monthly limit. It s called the Over the Limit List. After you ve reached your monthly limit (of 5 prescriptions or 2 brand name prescriptions), your doctor can get TennCare s OK to pay for prescriptions on this list. (Drug stores may call it the Prescriber Attestation list.) To get an Over the Limit OK, all of these things must be true: 1. The medicine must be on the Over the Limit list. 2. And, your doctor must call your TennCare pharmacy plan to ask for an Over the Limit OK. 3. And, your doctor must sign an OK page from your TennCare pharmacy plan and fax it back within 3 business days (not counting weekends or holidays). What if it s a medicine on the Over the Limit list that you only need one time? The page your doctor must sign says if you don t get this medicine, one of these things will probably happen in the next 90 days: 1. You will need to go into the hospital. 2. Or, you won t be able to live at home anymore. (You ll have to go to a nursing home.) 3. Or, you may die. If your doctor faxes the signed page back to your pharmacy health plan, you ll get an OK to go over your limit for this medicine one time. If you need the medicine again, your doctor must get another Over the Limit OK. What if it s a medicine on the Over the Limit list that you need to keep getting for a long time? The page your doctor must sign says you must get this medicine and all the other medicines TennCare pays for each month. It says that if you don t, one of these things will probably happen in the next 90 days: 1. You will need to go into the hospital. 2. Or, you won t be able to live at home anymore. (You ll have to go to a nursing home.) 3. Or, you may die. If your doctor faxes the signed page back to your pharmacy health plan, you ll get an OK to over your limit for this medicine. That Over the Limit OK will last until your prescription runs out (but no more than 1 year). Important: Remember, some medicines need TennCare s OK even before you go over your limit. That s a different kind of OK called a Prior Authorization or PA. Medicines on the Over the Limit list may need a PA too. If so, you ll need both OKs to get a medicine on the Over the Limit list. Your doctor can help you get both OKs if you need them. 32

36 What if a medicine on the Over the Limit list needs a PA and you don t have one? Then, TennCare still won t pay for the medicine. If your doctor asks for a PA and we turn you down, we ll send you a letter that says why. It will say how to appeal if you think we made a mistake. The Over the Limit list may change. To find out if a medicine is on the list, talk to your doctor or drug store. If you want to see the most current list, you can use the internet. Go to the TennCare website at Click on Over the Limit. Or, call the Tennessee Health Connection at Ask them to mail you a copy. Helpful Tips: If the medicine you re taking is more than your limit, ask your doctor if you need all the medicine you re taking. If you do, ask your drug store to help you pick the medicines that cost the most. Each month, get those filled first so TennCare will pay for them. Ask your doctor or drug store to find out if your medicine is on the Exempt List. Ask your doctor to prescribe medicines that are on the PDL. Ask your doctor to prescribe generic medicines whenever he or she can. Ask your doctor if your prescription needs a PA before you go to the pharmacy. If you have questions about your TennCare prescription coverage, call TennCare s pharmacy help desk at It s a free call. If you have questions about your prescription medicines, call your doctor first. If you have problems getting your prescription medicines, see Part 5 of this handbook. Important if you have Medicare: Are you an adult age 21 or older and have Medicare? You get your prescription medicine from Medicare Part D, not from TennCare s Pharmacy Program. Are you a child under age 21 and have Medicare? You get most of your prescription medicine from Medicare Part D. TennCare does not pay the co-pay for the medicines Medicare Part D covers. TennCare will only pay for your prescription medicines if: It s a kind of medicine that TennCare covers. And, it s a kind of medicine that Medicare doesn t cover. Part 4 of this handbook tells you more about how TennCare works with Medicare. 2. Trigger point injections (shots) The medicine is given with a needle in muscles that are knotted or very tense. TennCare will only pay for 4 trigger point injections in each muscle group every 6 months for adults age 21 and older. A muscle group means the muscles in a certain area of your body, like the muscles that make up your upper arm or your back. We ll count each time you get a shot in one muscle group for 6 months in a row. 33

37 What if you get trigger point shots in 2 muscle groups, like in your upper arm and in your back? We ll count them separately. We ll count up to 4 shots in your arm and up to 4 shots in your back during one 6 month period of time. 3. Medial nerve blocks used to diagnose (figure out) the cause of back pain Numbing medicine is given with a needle near nerves that are on each side of your spinetenncare will only pay for 4 medial nerve blocks each year given to diagnose the reason for your back pain. We ll start counting on January 1st and stop counting on December 31st every year. Each year we ll pay for up to 4 diagnostic medial nerve blocks. 4. Epidural injections (shots) The medicine is given with a needle around the spine. TennCare will only pay for 3 epidural shots every 6 months for adults age 21 and older. We ll count each one you get for 6 months in a row. But, TennCare will still pay for epidural shots women need during childbirth. 5. Urine Drug Screenings These are drug tests that look for proof of illegal or controlled substances in your urine. Controlled substances are prescriptions that can be abused, like Lortab and OxyContin. TennCare will only pay for 12 urine drug screenings per year for adults age 21 and older. 6. Private Duty Nursing and Home Health Services Private duty nursing and home health services are covered as medically necessary for children under the age of 21. But, these services work differently for adults age 21 or older. Private Duty Nursing TennCare will not cover Private Duty Nursing (PDN) services for adults age 21 or older unless: You are ventilator dependent for at least 12 hours each day. Or, you have a functioning tracheotomy and need certain other kinds of nursing care too. For your safety, to get Private Duty Nursing, you must have a relative or other person who can: Care for you when the private duty nurse is not with you And take care of your other non-nursing needs. If you qualify for PDN, your nurse will only be able to go with you to doctor s appointments, school and work. Even though your nurse may go with you to these places, your nurse cannot drive you there. TennCare rules say your nurse can t drive you anywhere. What if you need care at home but don t qualify for Private Duty Nursing? You may still be able to get care at home. This care is called Home Health Care. Home Health Care There are 2 kinds of Home Health Care: Home Health Nursing and Home Health Aide Care. There are limits on the amount of Home Health Nurse and Home Health Aide Care you can get. Part-time and intermittent Home Health Nursing Care 34

38 A home health nurse is someone who can visit you at home to provide medical care. TennCare will only pay for: Up to 1 nurse visit each day Each visit must be less than 8 hours long And, no more than 27 hours of nursing care each week (30 hours each week if you qualify for care in a skilled nursing home) Home Health Aide Care A home health aide is someone to help you with certain things you can t do alone (like eat or take a bath). TennCare will only pay for: Up to 2 home health aide visits each day No more than 8 hours of home health aide care each day And, no more than 35 hours a week of home health care (40 hours each week if you qualify for care in a skilled nursing home) What if you need both Home Health Nursing and Aide care? TennCare will only pay for: Up to 1 nurse visit per day Up to 2 home health aide visits per day No more than 8 hours of nursing and home health aide care combined each day No more than 27 hours of nursing care each week (30 hours per week if you qualify for care in a skilled nursing home) No more than 35 hours of nursing and home health aide care combined each week (40 hours per week if you qualify for care in a skilled nursing home) TennCare will only pay for nursing services if you need care that can only be given by a nurse (care that can t be given by an aide). This is care like tube feeding or changing bandages. TennCare won t pay for a nurse if the only reason you need a nurse is because you might need to take medicine. The nurse will only stay with you as long as you need nursing care. 6. Vision Services For adults age 21 and older, vision services are limited to medical evaluation and management of abnormal conditions and disorders of the eye. The first pair of cataract glasses or contact lens/lenses after cataract surgery are covered. Other TennCare Services TennCare CHOICES in Long-Term Services and Supports Program TennCare CHOICES in Long-Term Services and Supports (or CHOICES for short) is TennCare s program for long-term services and supports. Long-term services and supports include help doing everyday activities that you may no longer be able to do for yourself as you grow older, or if you have a disability like bathing, dressing, getting around your home, preparing meals, or doing household chores. Long-term services and supports include care in a nursing home. Long-term services and supports also include care in your own home or in the community that may keep you from having to go to a nursing home for as long as possible. These are called Home and Community Based Services or HCBS. More information about CHOICES is found in Part 3 of this handbook. 35

39 Special Services - Some services are covered by TennCare only in special cases. These are services like Population Health Hospice Care, Sterilization, Abortion, and Hysterectomy. More about these services can be found below. Population Health If you are well Population Health services provide you with information on how to stay healthy. If you have an ongoing illness or an unhealthy behavior Population Health services can help you do things like: Understand your illness and how to feel better Quit Smoking Manage your weight Have a healthy pregnancy and healthy baby. Population Health services are provided whether you are well, have an ongoing health problem or have a terrible health episode. Population health services are available to you depending on your health risks and need for the service. Population Health can provide you with a care manager. A care manager can help you get all the care you need. You may be able to have a care manager if you: Go to the ER a lot, or if you have to go into the hospital a lot, or Need health care before or after you have a transplant, or Have a lot of different doctors for different health problems or Have an ongoing illness that you don t know how to deal with. To see if you can have a care manager, or if you want to participate in the population health services, you (or someone on your behalf) can call BlueCare Population Health at Hospice Care Hospice Care is a kind of medical care for people who are terminally ill. You must use a hospice provider in our network. For help with hospice care, call us at Sterilization is the medical treatment or surgery that makes you not able to have children. To have this treatment, you must: Be an adult age 21 or older. Be mentally stable and able to make decisions about your health. Not be in a mental institution or in prison. Fill out a paper that gives your OK. This is called a Sterilization Consent Form. You can call us at to get this paper. You have to fill the paper out at least 30 days before you have the treatment. But in an emergency like premature delivery or abdominal surgery, you can fill the paper out at least 72 hours before you have the treatment. Abortion is the medical treatment that ends a pregnancy. TennCare pays for this treatment only if: 36

40 You are pregnant because of rape or incest, or You have a physical problem, injury, or illness that you could die from without an abortion. Your doctor must fill out a paper called Certification of Medical Necessity for Abortion. Hysterectomy A hysterectomy is medical surgery that removes reproductive organs. A hysterectomy can be covered when you must have it to fix other medical problems. After a hysterectomy, you will not be able to have children. But, TennCare will not pay for this treatment if you have it just so you won t have children. TennCare pays for this treatment only if it is medically necessary. You have to be told in words and in writing that having a hysterectomy means you are not able to have children. You have to sign a paper called Statement of Receipt of Information concerning Hysterectomy. 37

41 Preventive Care care that keeps you well TennCare covers preventive care for adults and children. Preventive care helps to keep you well and catches health problems early so they can be treated. Note! Even if you have co-pays for your health care, you will not have co-pays for preventive care. Some preventive care services are: Checkups for adults and children Care for women expecting a baby Well baby care Shots and tests Birth control information Preventive Care for Adults You can do some things for yourself to stay healthy: Stay active Eat right Exercise Don t smoke Don t drink alcohol or take drugs Do self-examinations Take medicine just as your doctor says Get regular checkups You can go to your PCP for a check up to help you stay healthy. Your PCP may want to do tests to make sure you are OK. Some of these tests are for: Cholesterol STDs (sexually transmitted diseases) Blood sugar HIV and AIDS Colon and rectal cancer Heart problems (EKG tests) Bone hardness TB (tuberculosis) (osteoporosis) Well-woman checkups (pap smears Thyroid and mammogram) You can get shots at your check up too. These shots are called vaccinations. Some of these shots may be for: Tetanus Flu Hepatitis B Measles Pneumonia Mumps Women s Health and Pregnancy Well-woman checkups TennCare covers some health care services that are special for women. These are well-woman checkups that help to keep you healthy. This kind of care is called preventive care. There are no co-pays for well-woman checkups. Starting at age 21, all women should get pap smears on a regular basis. A pap smear is a screening test to check for cervical cancer and other problems. 38

42 Starting at age 40, women should also have a mammogram every 1 to 2 years. A mammogram is an X-ray of the breast. It is used to check for breast cancer and other problems. Sometimes if you have family members who have had cervical or breast cancer, your doctor may want you to start having pap smears and mammograms earlier or more often, to make sure you are OK. You can get well-woman checkups from your PCP, or from a specialist called an Obstetrician / Gynecologist. This kind of specialist is sometimes called an OB/GYN doctor. You do not have to see your PCP first to go to an OB/GYN doctor. But, the OB/GYN doctor must still be in our Provider Directory so that TennCare will pay for the services. Pregnancy If you are pregnant, you should get health care now, so that you have a safer delivery. Health care while you are pregnant can help you to have a healthier baby. Care before your baby is born is called prenatal care. There are no co-pays for prenatal care. You can get this kind of health care from your PCP, or from a specialist called an Obstetrician/ Gynecologist. This kind of specialist is sometimes called an OB/GYN doctor. You do not have to see your PCP first to go to an OB/GYN doctor. But, the OB/GYN doctor must still be in our Provider Directory so that TennCare will pay for the services. If you are already more than three months pregnant and you are already seeing an OB/GYN doctor when you get your TennCare, you can still see that doctor to get your care. But, he or she has to say OK to the amount that TennCare pays. Call us at to find out if you can still see this doctor. We may ask you to change to an OB/GYN doctor who is in our Provider Directory if it is safe to change. Go to all of your OB/GYN visits, even if you feel fine. Your doctor will tell you how often to have checkups while you are pregnant. After your first visit, you may see your doctor every 4 weeks. Then, after 7 months, you may see your doctor every 2 or 3 weeks. When it gets close to when your baby is due, you may see your doctor every week. Do what your doctor says to take good care of you and your baby. Remember to take the vitamins that your doctor tells you to. Don t smoke or drink alcohol while you are pregnant. If your doctor prescribes medicine for you while you are pregnant, you do not have to pay a co-pay for it at the drug store. But, you have to tell the pharmacist that you are pregnant so he will not charge you a co-pay. After your baby is born, you should have follow-up care for you and your baby. Care after your baby is born is called postnatal care. Postnatal care includes circumcisions done by a doctor and special screenings for newborns. Both you and your baby need follow-up care. You should see your doctor 4 to 6 weeks after you have your baby. Your doctor will check to make sure you are OK. 39

43 You must find a PCP for your baby. It is a good idea to choose a PCP for your baby before he or she is born. The baby s doctor must be in our Provider Directory for TennCare to pay for health care services. Your baby should have a check up by the PCP soon after birth. Call the doctor ahead of time to make the appointment for your baby s check up. Well-baby checkups are part of TENNderCare. Read more about TENNderCare on the next pages. TennCare will cover your baby when he or she is born. Important! Tell the Tennessee Health Connection about your baby as soon as possible so you can make sure he or she gets on TennCare. Here s how to make sure your baby gets on TennCare: After your baby is born, the hospital will give you papers to get a Social Security number for your baby. Fill out those papers and mail them to the Social Security office. Tell the Tennessee Health Connection about your baby as soon as you can. Call them at Tell them that you have filled out papers for the baby s Social Security number. When you get your baby s Social Security card in the mail, call the Tennessee Health Connection again. Give them your baby s Social Security number. If you don t tell them your baby s Social Security number, your baby may lose TennCare. It is important to do these things before your baby is one month old, if possible. Preventive Care for Children: TENNderCare - health care for your child and teen Check In, Check Up, and Check Back! TENNderCare is the name for TennCare s program to keep children healthy. It used to be called EPSDT (Early Periodic Screening, Diagnosis and Treatment). Your child and teen need regular health checkups, even if they seem healthy. These visits help your doctor find and treat problems early. In TENNderCare, checkups for children are free until they reach age 21. TENNderCare also pays for all medically necessary care and medicine to treat problems found at the check up. This includes medical, dental, speech, hearing, vision, and behavioral (mental health, alcohol or drug abuse problems). If your child hasn t had a check up lately, call your child s PCP today for an appointment. Ask for a TENNderCare check up. You can go to your child s PCP or the Health Department to get TENNderCare checkups. And if someone else, like your child s teacher, is worried about your child s health, you can get a TENNderCare check up for your child. TENNderCare checkups include: health history complete physical exam/dental checkups 40 lab tests if needed immunizations or shots

44 vision and hearing tests developmental and behavioral tests if needed advice on how to keep your child healthy 41

45 If your child s doctor finds anything wrong, TENNderCare also gives your child the medical, dental, speech, hearing, vision, and behavioral (mental health, alcohol or drug abuse) treatment that he or she needs. Children should go to the doctor for checkups even if they are not sick. They should have TENNderCare checkups when they are at birth 12 months 3-5 days old 15 months 1 month 18 months 2 months 24 months 4 months 30 months 6 months 3 years 9 months and then every year until age 21 The vaccination shots that children need to get, to keep from getting sick, are for: Diphtheria Flu (influenza) Tetanus Hepatitis A and B Pertussis Chicken pox (varicella) Polio Pneumococcal Measles Rotavirus Mumps Human papillomavirus (HPV) Rubella (MMR) Meningitis HIB Look at the schedule of shots listed in Part 9 of this handbook. It is called TENNderCare: Children and Teen Immunization Schedule. It will help you know when your child should get his or her shots. Or, you can ask your child s doctor when your child should get his or her shots. More about TENNderCare can be found in Part 9 of this handbook. Dental care for children (for teeth) If you are a child under the age of 21, you also have a dental plan for your teeth called DentaQuest. Their phone number is You can call DentaQuest to find a dentist. Or, if you have questions about caring for your child s teeth, you can call them. It s a free call. Children s teeth need special care. Children under age 21 can have a check up and cleaning every six months. Children need to start seeing a dentist by age 3 or even earlier for some children. TennCare will pay for other dental care if it is medically necessary. Braces are covered only if they are medically necessary. You do not need to see your PCP before you go to a dentist. But, you will need to go to a DentaQuest dentist. This dental care is only for children under age 21. TennCare does not pay for any dental care for adults. 42

46 Vision care for children (for eyes) Children s eyes also need special care. Children under 21 years old can have their eyes checked and get eyeglass lenses and frames as medically necessary. If the eyeglass lenses or frames are broken or lost, we will replace them as medically necessary. Your BlueCare eye doctor will show you which frames you can choose from. TennCare will pay for other vision care if it is medically necessary. Contacts are covered only if they are medically necessary. Children do not have to see their PCP before seeing their BlueCare eye doctor. But, the eye doctor must still be in our Provider Directory. Find our online Provider Directory by visiting bluecare.bcbst.com Non- Services Here is a general list of some services that are not covered for anyone by TennCare. You can find a full list of services that TennCare will not pay for, online in the TennCare rules at Or, you can call us at for a full list. Some Non- Services are: 1. Services that are not medically necessary. But preventive care (care you need to stay well) is covered. 2. Services that are experimental or investigative. 3. Surgery for your appearance. But if you had a mastectomy, reconstructive breast surgery is covered. 4. Reversal of sterilization. 5. Artificial insemination, in-vitro fertilization or any other treatment to create a pregnancy. 6. Treatment of impotence. 7. Any medical or behavioral health (mental health, alcohol or drug abuse) treatment outside of the United States. 8. Autopsy or necropsy. 9. Physical exams that a new job says you need. 10. Any medical or behavioral health (mental health, alcohol or drug abuse) treatment if you are in local, state, or federal jail or prison. 11. Services that are covered by workers compensation insurance. 12. Services that you got before you had TennCare or after your TennCare ends. 13. Personal hygiene, luxury, or convenience items. 14. Convalescent Care and Sitter Services. 15. Services mainly for convalescent care or rest cures. 16. Foot care for comfort or appearance, like flat feet, corns, calluses, toenails. 17. Transsexual surgery and any treatment connected to it. 18. Radial keratotomy or other surgery to correct a refractive error of the eye. 19. Services given to you by someone in your family or any person that lives in your household. 43

47 20. Medicines for: hair growth treatment of impotence cosmetics treatment of infertility controlling your appetite 21. Medicines that the FDA (Food and Drug Administration) says are: DESI this means that research says they are not effective LTE this means that research says they are less than effective IRS this means that the medicines are identical, related, or similar to LTE medicines. Some services are covered for children under age 21 but not for adults. Services that are not covered for adults include: 1. Over the counter medicine (except prescribed pre-natal vitamins) 2. Allergy medicines you get from the pharmacy even if you have a prescription 3. Medicine to treat acne and rosacea 4. Dental Services 5. Methadone clinic services 6. Eyeglasses, contact lens or eye exams for adults age 21 and older. But if you had cataract surgery, your first pair of cataract glasses or contact lens/lenses is covered. 7. Hearing aids or exams for your hearing for adults age 21 and older. 44

48 Part 3: TennCare CHOICES in Long-Term Services and Supports Program What is CHOICES? TennCare CHOICES in Long-Term Services and Supports (or CHOICES for short) is TennCare s program for long-term services and supports. Long-term services and supports includes help doing everyday activities that you may no longer be able to do for yourself as you grow older, or if you have a disability activities like bathing, dressing, getting around your home, preparing meals, or doing household chores. Long-term services and supports include care in a nursing home. Long-term services and supports also includes care in your own home or in the community that may keep you from having to go to a nursing home for as long as possible. These are called Home and Community Based Services or HCBS. How do I apply for CHOICES? If you think you need long-term services and supports, call us at We may use a short screening that will be done over the phone to help decide if you may qualify for CHOICES. If the screening shows that you don t appear to qualify for CHOICES, you ll get a letter that says how you can finish applying for CHOICES. If the screening shows that you might qualify for CHOICES, or if we don t conduct a screening over the phone, we will send a Care Coordinator to your home to do an assessment. The purpose of the in-home assessment is to help you apply for CHOICES. It s also to find out: The kinds of help you need; The kinds of care being provided by family members and other caregivers to help meet your needs; And the gaps in care for which paid long-term services and supports may be needed. If you want to receive care at home or in the community (instead of going to a nursing home), the assessment will help decide if your needs can be safely met in the home or community setting. And, for CHOICES Group 2 (you can read about all of the CHOICES Groups below), it will help decide if the cost of your care would exceed the cost of nursing home care. This doesn t mean that you will receive services up to the cost of nursing home care. CHOICES won t pay for more services than you must have to safely meet your needs at home. And, CHOICES only pays for services to meet long-term services and supports needs that can t be met in other ways. CHOICES services provided to you in your home or in the community will not take the place of care you get from family and friends or services you already receive. If you re getting help from community programs, receive services paid for by Medicare or other insurance, or have a family member that takes care of you, these services will not be replaced by paid care through CHOICES. Instead, the home care you receive through CHOICES will work together with the assistance you already receive to help you stay in your home and community longer. Care in CHOICES will be provided as cost-effectively as possible so that more people who need care will be able to get help. 45

49 However, if you have been getting services through the State-funded Options program, you won t qualify to get those services anymore. They are for people who can t get Medicaid. And if you ve been getting services from programs funded by the Older Americans Act (like Meals on Wheels, homemaker, or the National Caregiver Family Support Programs) that you can now get through CHOICES, you ll get the care you need through CHOICES. If you want home care, the Care Coordinator will also perform a risk assessment. This will help to identify any additional risks you may face as a result of choosing to receive care at home. It will also help to identify ways to help reduce those risks and to help keep you safe and healthy. You will be asked to sign a risk agreement saying that you understand the risks and what could happen, and are choosing to receive care at home. To see if you qualify to enroll in CHOICES, call us at Does someone you know that isn t on TennCare want to apply for CHOICES? They should contact their local Area Agency on Aging and Disability (AAAD) for free at Their local AAAD will help them find out if they qualify for TennCare and CHOICES. Who can qualify to enroll in CHOICES? For now, there are three (3) groups of people who can qualify to enroll in CHOICES. CHOICES Group 1 is for people of all ages who receive nursing home care. To be in CHOICES Group 1, you must: Need the level of care provided in a nursing home; And qualify for Medicaid long-term services and supports; And receive nursing home services that TennCare pays for. TennCare Long-Term Services and Supports will decide if you need the level of care provided in a nursing home. TennCare Member Services will decide if you qualify for Medicaid long-term services and supports. We ll help you fill out the papers TennCare needs to decide. What if TennCare says yes? If you re receiving nursing home services that TennCare will pay for, TennCare will enroll you into CHOICES Group 1. If TennCare says you don t qualify, you ll get a letter that says why. It will say how to appeal if you think it s a mistake. CHOICES Group 2 is for certain people who qualify for nursing home care, but choose to receive home care instead. To be in CHOICES Group 2, you must: Need the level of care provided in a nursing home; And qualify for Medicaid long-term services and supports because you receive SSI payments OR because you need and will receive home care services instead of nursing home care. And be an adult 65 years of age or older; Or be an adult 21 years of age or older with a physical disability. If you need home care services, but don t qualify in one of these groups, you can t be in CHOICES Group 2, but you may qualify for other kinds of long term services and supports. 46

50 TennCare Long-Term Services and Supports will decide if you need the level of care provided in a nursing home. TennCare Member Services will decide if you qualify for Medicaid long-term services and supports for one of the reasons listed above. We ll help you fill out the papers they need to decide. If TennCare says yes, to enroll in CHOICES Group 2 and begin receiving home care services: We must be able to safely meet your needs at home. And, the cost of your home care can t be more than the cost of nursing home care. The cost of your home care includes any home health or private duty nursing care you may need. If we can t safely meet your needs at home, or if your care would cost more than nursing home care, you can t be in CHOICES Group 2. But, you may qualify for other kinds of long-term services and supports. If TennCare says you don t qualify, you ll get a letter that says why. It will say how to appeal if you think it s a mistake. CHOICES Group 3 is for certain people who don t qualify for nursing home care, but need home care to help them stay at home safely. To be in CHOICES Group 3, you must: Be at risk of going into a nursing home unless you receive home care; And qualify for Medicaid long-term services and supports because you receive SSI payments OR because you need and will receive home care services to keep you from going into a nursing home. And be an adult 65 years of age or older; Or be an adult 21 years of age or older with a physical disability. TennCare Long-Term Services and Supports will decide if you are at risk of going into a nursing home. TennCare Member Services will decide if you qualify for Medicaid long-term services and supports for one of the reasons listed above. We ll help you fill out the papers they need to decide. If TennCare says yes, to enroll in CHOICES Group 3 and begin receiving home care services: We must be able to safely meet your needs at home with the care you d get in CHOICES Group 3 If we can t safely meet your needs with the care you d get in CHOICES Group 3, you can t be in CHOICES Group 3. But, TennCare may decide that you qualify for other kinds of long-term services and supports, including nursing home care. Limits on Enrollment into CHOICES Group 2 Not everyone who qualifies to enroll in CHOICES Group 2 may be able to enroll. There is an enrollment target for CHOICES Group 2. It s like a limit on the number of people who can be in the group at one time. (The number of people who can enroll is sometimes called slots.) This helps to ensure that the program doesn t grow faster than the State s money to pay for home care. It also helps to ensure that there are enough home care providers to deliver needed services. 47

51 The enrollment target for the number of slots that can be filled in CHOICES Group 2 will be set by the State in TennCare Rules. It doesn t apply to people moving out of a nursing home. And, it may not apply to some people who are on TennCare that would have to go into a nursing home right away if less costly home care isn t available. We must decide if you would go into a nursing home right away and provide proof to TennCare. And, we must show TennCare that there are home care providers ready to start giving your care at home. Some slots will be held back (or reserved) for emergencies. This includes things like when a person is leaving the hospital and will be admitted to a nursing home if home care isn t available. Reserved slots won t be used until all of the other slots have been filled. The number of reserved slots and the guidelines to qualify in one of those slots is in TennCare Rules. If the only slots left are reserved, you ll have to meet the guidelines for reserved slots to enroll in CHOICES Group 2. If you don t meet the guidelines for reserved slots or there are no slots available and you qualify to enroll in CHOICES Group 2, your name will be placed on a waiting list. Or, you can choose to enroll in CHOICES Group 1 and receive nursing home care. There is no limit on the number of people that can be enrolled in Group 1 and go into a nursing home. (But, you don t have to receive nursing home care unless you want to. You can wait for home care instead.) People enrolled in CHOICES Group 2 above the enrollment target must get the first slots that open up. (These are people who have moved out of nursing homes or people already on TennCare would have gone into a nursing home right away if less costly home care wasn t available.) When everyone in CHOICES Group 2 is under the enrollment target and there are still slots available, TennCare can enroll from the waiting list based on need. What long-term services and supports are covered in CHOICES? The covered long-term services and supports you can receive in CHOICES depend on the CHOICES Group you re enrolled in. If you enroll in CHOICES, TennCare will tell you which CHOICES Group you re in. There are three (3) CHOICES Groups. People in CHOICES Group 1 receive nursing home care. People in CHOICES Group 2 receive home care (or HCBS) instead of nursing home care. Here are the kinds of home care covered in CHOICES Group 2. Some of these services have limits. This means that TennCare will pay for only a certain amount of these services. The kind and amount of care you get in CHOICES depends on your needs. Personal care visits (up to 2 visits per day, lasting no more than 4 hours per visit; there must be at least 4 hours between each visit.) Hands-on help with self care tasks like getting out of bed, taking a bath, getting dressed, eating meals, or using the bathroom. Do you need this kind of hands-on care? If you do, the worker giving your personal care visits can also help with household chores like fixing meals, cleaning, or laundry. And they can run errands like grocery shopping or picking up your medicine. They can only help with those things for you, not for other family members who aren t in CHOICES. And they can only do those things if there s no one else that can do them for you. Attendant care (up to 1,080 hours per calendar year) The same kinds of help you d get with personal care visits, but for longer periods of time (more than 4 hours per visit or visits 48

52 less than 4 hours apart). You can only get attendant care when your needs can t be met with shorter personal care visits. Do you need hands-on help with self-care tasks and also need help with household chores or errands? If so, your attendant care limit increases to up to 1,400 hours per calendar year. This higher limit is only for people who also need help with household chores or errands. How much attendant care you get depends on your needs. Home-delivered meals (up to 1 meal per day). Personal Emergency Response System - A call button so you can get help in an emergency when your caregiver is not around. Adult day care (up to 2,080 hours per calendar year) - A place that provides supervised care and activities during the day. In-home respite care (up to 216 hours per calendar year) - Someone to come and stay with you in your home for a short time so your caregiver can get some rest. In-patient respite care (up to 9 days per calendar year) A short stay in a nursing home or assisted care living facility so your caregiver can get some rest. Assistive technology (up to $900 per calendar year) Certain low-cost items or devices that help you do things easier or safer in your home like grabbers to reach things. Minor home modifications (up to $6,000 per project; $10,000 per calendar year; and $20,000 per lifetime) Certain changes to your home that will help you get around easier and safer in your home like grab bars or a wheelchair ramp. Pest control (up to 9 units per calendar year) - Spraying your home for bugs or mice. Assisted Care Living Facility - A place you live that helps with personal care needs and taking your medicine. You must pay for your room and board. Critical Adult Care Home A home where you and no more than 4 other people live with a health care professional that takes care of special health and long-term services and supports needs. (Under state law, available only for people who are ventilator dependent or who have traumatic brain injury. You must pay for your room and board.) Companion Care Someone you hire who lives with you in your home to help with personal care whenever you need it. (Available only for people in Consumer Direction who need care throughout the day and night that can t be provided by unpaid caregivers. And only when it costs no more than other kinds of home care that would meet your needs.) 49

53 People in CHOICES Group 3 receive services at home because they re at risk of going into a nursing home. The total cost of home care services are limited to $15,000 per year. But, minor home modifications don t count against the $15,000 limit. Here are the kinds of home care covered in CHOICES Group 3. Some of these services also have limits. This means that TennCare will pay for only a certain amount of these services. The kind and amount of care you get in CHOICES depends on your needs. Please note that people in Group 3 are not eligible for Companion Care or services in an Assisted Care Living Facility or Critical Adult Care Home. Personal care visits (up to 2 visits per day, lasting no more than 4 hours per visit; there must be at least 4 hours between each visit.) Hands-on help with self care tasks like getting out of bed, taking a bath, getting dressed, eating meals, or using the bathroom. Do you need this kind of hands-on care? If you do, the worker giving your personal care visits can also help with household chores like fixing meals, cleaning, or laundry. And they can run errands like grocery shopping or picking up your medicine. They can only help with those things for you, not for other family members who aren t in CHOICES. And they can only do those things if there s no one else that can do them for you. ) Attendant care (up to 1,080 hours per calendar year) The same kinds of help you d get with personal care visits, but for longer periods of time (more than 4 hours per visit or visits less than 4 hours apart). You can only get attendant care when your needs can t be met with shorter personal care visits. Do you need hands-on help with self-care tasks and also need help with household chores or errands? If so, your attendant care limit increases to up to 1,400 hours per calendar year. This higher limit is only for people who also need help with household chores or errands. How much attendant care you get depends on your needs. Home-delivered meals (up to 1 meal per day). Personal Emergency Response System - A call button so you can get help in an emergency when your caregiver is not around. Adult day care (up to 2,080 hours per calendar year) - A place that provides supervised care and activities during the day. In-home respite care (up to 216 hours per calendar year) - Someone to come and stay with you in your home for a short time so your caregiver can get some rest. In-patient respite care (up to 9 days per calendar year) A short stay in a nursing home or assisted care living facility so your caregiver can get some rest. Assistive technology (up to $900 per calendar year) Certain low-cost items or devices that help you do things easier or safer in your home like grabbers to reach things. Minor home modifications (up to $6,000 per project; $10,000 per calendar year; and $20,000 per lifetime) Certain changes to your home that will help you get around easier and safer in your home like grab bars or a wheelchair ramp. (Remember: home modifications do not count against your $15,000 per year limit on home care services). Pest control (up to 9 units per calendar year) - Spraying your home for bugs or mice. 50

54 Care Coordination and Role of the Care Coordinator In CHOICES, we are responsible for managing all of your physical health, behavioral health (mental health, alcohol or drug abuse) and long-term services and supports needs, and the services that you receive to address these needs. This is called care coordination. These functions are carried out by a Care Coordinator. We will assign you a Care Coordinator when you enroll in CHOICES. Your Care Coordinator will play a very important role. Your Care Coordinator is your contact person and is the first person that you should go to if you have any questions about your services. Your Care Coordinator will Provide information about CHOICES and answer your questions. Work with you to ensure that you have all the information you need to make good choices about your health care. Help you get the right kind of long-term services and supports in the right setting for you to address your needs. Coordinate all of your physical health, behavioral health (mental health, alcohol or drug abuse) and long-term services and supports needs. Help to fix problems and answer questions that you have about your care. Make sure that your plan of care is carried out and is working the way that it needs to. Be aware of your needs as they change, update your plan of care when needed (at least once a year), and make sure that the services you get are appropriate for your changing needs. Check at least once a year to make sure that you continue to need the level of care provided in a nursing home. Communicate with your providers to make sure they know what s happening with your health care and to coordinate your service delivery. Other tasks performed by the Care Coordinator will vary slightly depending on the CHOICES Group you re enrolled in. If you receive nursing home care in CHOICES Group 1, your Care Coordinator will Be part of the care planning process with the nursing home where you live. Perform any additional needs assessment that may be helpful in managing your health and long-term services and supports needs. Supplement (or add to) the nursing home s plan of care if there are things BlueCare can do to help manage health problems or coordinate other kinds of physical and behavioral health (mental health, alcohol or drug abuse) care you need. Conduct face-to-face visits at least every 6 months. Coordinate with the nursing home when you need services the nursing home isn t responsible for providing. Determine if you re interested and able to move from the nursing home to the community and if so, help make sure this happens timely. 51

55 If you receive home care in CHOICES Group 2 or Group 3, your Care Coordinator will Work with you to do a comprehensive, individual assessment of your health and longterm services and supports needs and determine the services most appropriate to meet those needs. Work with you to develop your individual plan of care. Make sure the right health care professionals are consulted during your plan of care process. Give you information to help you choose long-term services and supports providers who work with BlueCare. Contact you by telephone at least once every month and visit you in person at least once every 3 months. Make sure your plan of care is carried out and working the way that it needs to. Monitor to make sure you are getting what you need and that gaps in care are addressed right away. Give you information about community resources that might be helpful to you. Make sure the home care services you receive are based on your needs and do not cost more than nursing home care, if you are in Group 2, or more than $15,000 if you are in Group 3. We will tell you who your Care Coordinator is and how to reach them. If your Care Coordinator won t be assigned soon after you enroll in CHOICES, we will send a letter that says how to reach the Care Coordination Unit for help until your Care Coordinator is assigned. Requesting a TennCare Review If you re in CHOICES Group 2 or Group 3, you can ask TennCare to review your needs assessment or plan of care if you have concerns and think you re not getting the services you need. TennCare will review the assessment or plan of care and the information gathered by your Care Coordinator. If TennCare thinks you re right, they ll work with us to fix the problem. If TennCare thinks you are getting the services you need, they ll send you a letter that says why. To request an objective review of your needs assessment and plan of care, you must submit a written request to: TennCare Division of Long Term Services and Supports c/o CHOICES Review 310 Great Circle Rd. Nashville, TN Keep a copy of your request. Write down the date that you sent it to TennCare. Or, fax your request to Keep the page that shows your fax went through. Changing Care Coordinators If you re unhappy with your Care Coordinator and would like a different one, you can ask us. You can have a new Care Coordinator if one is available. That doesn t mean you can pick whoever you want to be your Care Coordinator. We must be able to meet the needs of all 52

56 CHOICES members and assign staff in a way that allows us to do that. To ask for a different Care Coordinator, call us at Tell us why you want to change Care Coordinators. If we can t give you a new Care Coordinator, we ll tell you why. And, we ll help to address any problems or concerns you have with your Care Coordinator. There may be times when we will have to change your Care Coordinator. This may happen if your Care Coordinator is no longer with BlueCare, is temporarily not working, or has too many members to give them the attention they need. If this happens, we will send you a letter that says who your new Care Coordinator will be and how to contact them. If you re in CHOICES, you can contact your Care Coordinator anytime you have a question or concern about your health care you do not need to wait until a home visit or a phone call. You should contact your Care Coordinator anytime you have a change in your health condition or other things that may affect the kind or amount of care you need. If you need help after regular business hours that won t wait until the next day, you can call us at CHOICES Consumer Advocate In addition to your Care Coordinator, there is another person at BlueCare to help you. This person is the CHOICES Consumer Advocate. The CHOICES Consumer Advocate is available to: Provide information about the CHOICES program. Help you figure out how things work at BlueCare, like filing a complaint, changing Care Coordinators or getting the care you need. Make referrals to the right BlueCare staff. Help fix problems with your care. To reach the BlueCare CHOICES Consumer Advocate, call us at Ask to speak with the CHOICES Consumer Advocate. Freedom of Choice In CHOICES, if you need the level of care provided in a nursing home, you have the right to choose to get care: In your home, Or in another place in the community (like an assisted living facility or critical adult care home), Or in a nursing home. To get care in your home or in the community, you must qualify and be able to enroll in CHOICES Group 2 or CHOICES Group 3. (See Who can qualify to enroll in CHOICES?) If you re in a nursing home, you may be able move from your nursing home to your own home and receive services if you want to. If you re interested in moving out of the nursing home into the community, talk with your Care Coordinator. To get care in your home or in the community, we must be able to safely meet your needs in that setting. And, for CHOICES Group 2 the cost of your care can t be more than the cost of your care in a nursing home. That includes the cost of your home care and any home health or nursing care you may need. For CHOICES Group 3, the cost of your care can t be more than 53

57 $15,000 per year. Minor home modifications, and any home health or nursing care you might need don t count against the $15,000 limit. The actual kind and amount of care you will receive depends on your needs. What if you qualify for nursing home care but don t want to leave the nursing home and move to the community? Then, we won t make you, even if we think care in the community would cost less. As long as you qualify for nursing home care, you can choose to receive it. You can change your choice at any time as long as you qualify and can enroll to receive care in the setting you pick. In CHOICES, you can also help choose the providers who will give your care. This could be an assisted living or nursing home, or the agency who will give your care at home. You may also be able to hire your own workers for some kinds of care (called Consumer Direction). The provider you choose must be willing and able to give your care. Your Care Coordinator will try to help you get the provider you pick. But, if you don t get the provider you want, you can t appeal and get a fair hearing. If you don t get the services you think you need, then you can file an appeal. Using Long-Term Services and Supports Providers Who Work with BlueCare Just like physical and behavioral health services, you must use providers who work with us for most long-term services and supports. You can find the Provider Directory online at bluecare.bcbst.com. Or call us at to get a list. Providers may have signed up or dropped out after the list was printed. But, the online Provider Directory is updated every week. You can also call us at to find out of a provider is in our network. In most cases, you must receive services from a long-term services and supports provider on this list so that TennCare will pay for your long-term services and supports. However, there are times when TennCare will pay for you to get care from a long-term services and supports provider who does not usually work with us. But, we must first say that it is OK to use a longterm services and supports provider who does not usually work with BlueCare. Prior Authorization of Long-Term Services and Supports Sometimes you may have to get an OK from us for your physical or behavioral health (mental health, alcohol or drug abuse) services before you receive them even if a doctor says you need the services. This is called prior authorization. Services that must have a prior authorization before you receive them will only be paid for if we say OK before the services are provided. All long-term services and supports must be approved before we will pay for them. All home care services must be approved before you receive them. Nursing home care may sometimes start before you get an OK, but you still need an OK before we will pay for it. We will not pay for any long-term services and supports unless you have an OK. Consumer Direction Consumer Direction is a way of getting some of the kinds of home care you need. It offers more choice and control over who gives your home care and how your care is given. The services available through Consumer Direction are: Personal care visits; 54

58 Attendant care; In-home respite; and Companion care (Only if you qualify for and are enrolled in CHOICES Group 2) In Consumer Direction, you actually employ the people who give some of your home care services they work for you (instead of a provider). You must be able to do the things that an employer would do. These include things like: Hiring and training your workers: Find, interview and hire workers to provide care for you Define workers job duties Develop a job description for your workers Train workers to deliver your care based on your needs and preferences Setting and managing your workers schedule: Set the schedule at which your workers will give your care Make sure your workers use the call-in system to log in and out every time they work Make sure your workers provide only as much care as you are approved to receive Make sure that no hourly worker gives you more than 40 hours of care in a week Supervising your workers: Supervise your workers Evaluate your workers job performance Address problems or concerns with your workers performance Fire a worker when needed Overseeing workers pay and service notes: Decide how much your workers will be paid (within limits set by the State) Review the time your workers report to be sure it s right Ensure there are good notes kept in your home about the care your workers provide Having and using a back-up plan when needed: Develop a back-up plan to address times that a scheduled worker doesn t show up (you can t decide to just go without services) Activate the back-up plan when needed What if you can t do some or all of these things? Then you can choose a family member, friend, or someone close to you to do these things for you. It s called a Representative for Consumer Direction. It s important that you pick someone who knows you very well that you can depend on. To be your Representative for Consumer Direction, the person must: Be at least 18 years of age. Know you very well. Understand the kinds of care you need and how you want care to be given. Know your schedule and routine. Know your health care needs and the medicine you take. 55

59 Be willing and able to do all of the things that are required to be in Consumer Direction. Live with you in your home or be present in your home often enough to supervise staff. This usually means at least part of every worker s shift. Be willing to sign a Representative Agreement, saying they agree to do these things. Your Representative cannot get paid for doing these things. You or your Representative will have help doing some of the things you must do as an employer. The help will be provided by Public Partnerships, LLC. There are 2 kinds of help you will receive: 1. Public Partnerships, LLC will help you and your workers fill out all of the paperwork that you must complete. They will pay your workers for the care they give. And, they will fill out and file the payroll tax forms that you must fill out as an employer. 2. Public Partnerships, LLC will hire or contract with a Supports Broker for you. A Supports Broker is a person who will help you with the other kinds of things you must do as an employer. These are things like: Finding and interviewing workers; Writing job descriptions; Training workers; Scheduling workers; and Developing a back-up plan to address times when a scheduled worker doesn t show up. But, your Supports Broker can t help you supervise your workers. You or your Representative must be able to do that by yourself. The kind and amount of care you ll get depends on what you need. Those services are listed in your plan of care. You won t be able to get more services by choosing to be in Consumer Direction. You can only get the services you need that are listed in your plan of care. You can choose to get some of these services through Consumer Direction and get some home care from providers that work with your TennCare health plan. But, you must use providers that work with BlueCare for care that you can t get through Consumer Direction. Can you pay a family member or friend to provide care in Consumer Direction? Yes, you can pay a family member, but you cannot: Pay your spouse to provide care; Pay someone who lives with you to provide Attendant Care, Personal Care, or In-home Respite services; Pay an immediate family member to provide Companion Care. An immediate family member is a spouse, parent, grandparent, child, grandchild, sibling, mother-in-law, father-in-law, sister-in-law, brother-in-law, daughter-in-law, and son-in-law. Adopted and step members are included in this definition; Pay someone who lives with you now or in the last 5 years to provide Companion Care. And, CHOICES can t pay family members or others to provide care they would have given for free. CHOICES only pays for care to meet needs that can t be met by family members or others who help you. The services you need are listed in your plan of care. 56

60 If you re in CHOICES and need services that can be consumer directed your Care Coordinator will talk with you about Consumer Direction. If you want to be in Consumer Direction, your Care Coordinator will work with you to decide which of the services you will direct and start the process to enroll you in Consumer Direction. Until Consumer Direction is set up, you will get the services that are in your plan of care from a provider who works with BlueCare, unless you choose to wait for your Consumer Directed workers to start. If you choose to wait for your Consumer Directed workers to start, you must have supports in place to give you the care you need. You can decide to be in Consumer Direction at any time. If you are directing one or more services and decide not to be in Consumer Direction any more, you will not stop getting longterm services and supports. You will still be in CHOICES. You ll get the services you need from a provider who works with BlueCare instead. Self-Direction of Health Care Tasks If you re in Consumer Direction, you may also choose to have consumer directed workers perform certain kinds of health care tasks for you. Health care tasks are routine things like taking prescribed drugs that most people do for themselves every day. Usually, if you can t perform health care tasks yourself and don t have a family member to do them for you, they must be performed by a licensed nurse. But, in Consumer Direction, if your doctor says it s OK, you can have your consumer directed workers do certain kinds of health care tasks for you. You (or your Representative) must be able to train your workers on how to do each health care task, and must supervise them in performing the task. For now, health care tasks are limited to giving medicine that isn t injected with a needle. These are drugs you take by mouth, or things like eye drops, or lotions and creams. And, the medicine must be prescribed for a set dose to be taken at a scheduled time (not as needed). Please talk with your Care Coordinator if you have any questions about self-direction of health care tasks. Paying for your CHOICES Long-Term Services and Supports You may have to pay part of the cost of your care in CHOICES. It s called patient liability. The amount you pay depends on your income. If you have patient liability, you must pay it in CHOICES. If you get care in an assisted living or adult care home, or in a nursing home, you will pay your patient liability to that home. If you get care in your own home, you will pay your patient liability to BlueCare. What if you DON T pay the patient liability you owe? 4 things could happen: 1. Your CHOICES care provider could decide not to provide your care anymore. If you get care in an assisted living or adult care home, or in a nursing home, they could discharge you. Before they do, they must send you a letter that says why you re being discharged. If you think they re wrong about owing them money, you can appeal. 2. And if you don t pay your patient liability, other providers may not be willing to give your care either. If that happens, BlueCare could decide not to be your health plan for CHOICES anymore. We can t meet your needs if we can t find any providers willing to give you care. We must send you a letter that says why we can t be your health plan for CHOICES anymore. If you think we re wrong, you can appeal. 57

61 3. And if you don t pay your patient liability, other TennCare health plans may not be willing to be your health plan for CHOICES either. If that happens, you may not be able to stay in CHOICES. You may not get any long-term services and supports from TennCare. If you can t stay in CHOICES, TennCare will send you a letter that says why. If you think they re wrong, you can appeal. 4. And if you can t stay in CHOICES, you may not qualify for TennCare anymore. If the only way you qualify for TennCare is because you get long-term services and supports, you could lose your TennCare too. Before your TennCare ends, you ll get a letter that says how to appeal if you think it s a mistake. If you have patient liability, it s very important that you pay it. Do you have Medicare or other insurance that helps pay for your long-term services and supports? If you do, that insurance must pay first. TennCare can t pay for care that s covered by Medicare or other insurance. What if you have long-term services and supports insurance that pays you? Then you must pay the amount you get to help cover the cost of your care. If you live in an assisted living or adult care home, or in a nursing home, you ll pay the amount you get to that home. If you get care in your own home, your Care Coordinator will tell you how to pay the insurance money you get. This won t lower the amount of any patient liability you owe. You must pay any long-term services and supports insurance you get and your patient liability to help cover the cost of your care. But, you won t pay more than the total cost of long term services and supports you receive that month. What if you receive Aid and Attendance Benefits through the Department of Veterans Affairs? If you do, it is important that you tell your Care Coordinator. Your Care Coordinator will give you important information that will help you make choices about how you will receive the longterm services and supports that you need. Federal Estate Recovery Program What is it and what does it mean for you? Your estate is made up of the things you own that you leave behind when you die. It includes your money, your home, other property, or other things you own. Estate recovery is using the value of things you leave behind when you die to pay TennCare back for care you received while you were living. Why you have to pay TennCare back for your care TennCare, including CHOICES services, are paid for by the State and federal government. If TennCare pays for any of your care, TennCare is required by federal law to try to get paid back for that care after your death. TennCare must ask to be repaid for money it spent on your care if you are: Any age and got nursing home care if you weren t expected to return home Or age 55 and older and got nursing home care, home care, home health or private duty nursing. TennCare must ask to be repaid for these services: Nursing home care Home care (CHOICES home care as well as home health or private duty nursing) Hospital care and prescription drugs you got while you re in CHOICES. 58

62 TennCare can also ask to be paid back for the cost of any other services we paid for. TennCare can t ask for the money back until after your death. TennCare can t ask for more money back than we paid for your care. And TennCare can t ask your family to pay for your care out of their own pockets. Sometimes TennCare may not have to get the money back from your estate. These times are: If you leave very little money or property when you die If your care did not cost much If the things you left can t be used to pay people you owe through probate court. An example is life insurance money. But these times do not happen by themselves. The person handling your things after you die must get a Release from TennCare. It says you don t owe TennCare money. If your things have to go through Probate court, the Release must be filed there. Sometimes TennCare must let your money or property stay in the family longer. These times are if you leave your money or property to: Your surviving husband or wife Your child who is under age 21 when you die Or your child of any age who is blind or permanently and totally disabled. TennCare won t try to get repaid until this family member dies or the child turns age 21. But the person who handles your things must file the TennCare Release in Probate Court. Sometimes TennCare must let just your HOME stay in the family longer. This happens when one of these family members lives in the home when you die: Your surviving husband or wife Your child who is under age 21 when you die Your child of any age who is blind or permanently and totally disabled Your child who lived in the home and took care of you if this care kept you out of a nursing home or home care for 2 years Or your brother or sister who helped make the house payments if they lived there for a year before you got nursing home or home care. By law, TennCare should not take the house until these family members die or the child turns 21. But the person who handles your things must file the TennCare Release in Probate court. TennCare may leave your money and property in the family because of undue hardship. But the State does not do this very often. The family must prove that losing the money or property in your estate will cause an undue hardship. For example, if your property is a family farm and the family s only income, then the person handling your things can ask the State not to take the property. The State may or may not agree. 59

63 The person handling your things after you die may apply for a Release in one of three ways: 1. They can get the Release online at 2. They can get the Release from the Probate Court Clerk s office by asking for a Request for Release from Estate Recovery. 3. They can get the Release from TennCare by sending a letter or fax to: Bureau of TennCare Estate Recovery Unit 310 Great Circle Road Nashville, TN FAX: (615) All of the information asked for in the Release must be included. And they must provide any other information TennCare requests to decide if the Release will be given. Please ask your Care Coordinator if you have questions about estate recovery. Disenrollment from CHOICES Your enrollment in CHOICES and receipt of long-term services and supports can end for several reasons and may vary depending on the CHOICES Group that you are enrolled in. We can recommend a member s disenrollment from CHOICES but TennCare will make the final decision. Some of the reasons you could be disenrolled from CHOICES include: You no longer qualify for Medicaid. You no longer need the level of care provided in a nursing home and you re not at risk of going into a nursing home. You no longer need and aren t receiving any long-term services and supports. You do not pay your patient liability. If you re in Group 2 or Group 3, your enrollment in CHOICES can also end if We decide we can no longer safely meet your needs in the home or community, and you refuse to move to a nursing home. Reasons we may not be able to safely meet your needs include things like: You refuse to allow a Care Coordinator into your home. If a Care Coordinator can t visit you in your home, we can t be sure that you re safe and healthy. The risk of harm to you or to people providing care in your home is too great. Even though there are providers available to provide care, none of those providers are willing to provide your care. You refuse to receive services that are identified in your plan of care as needed services. You refuse to sign a Risk Agreement, or the risks to your health and safety are too great. If you re in Group 2, you can also be disenrolled if: The cost of care you need in the home or community will be more than the cost of nursing home care. The cost of care includes any home health or private duty nursing you may need. 60

64 Your Care Coordinator will check regularly to make sure that the care you receive in your own home or in the community (including the cost of home health and private duty nursing) does not exceed the cost of nursing home care. If we decide that home care will cost more than nursing home care, your Care Coordinator will work with you to try to put together a plan of care that will safely and cost-effectively meet your needs. If we decide it s not possible to safely serve you in your home or in the community for no more than the cost of nursing home care, your Care Coordinator will help you move to a nursing home of your choice who works with BlueCare. If you choose not to move to a nursing home, you ll no longer be able to receive services in your own home or in the community. You ll be disenrolled from CHOICES. If you re in Group 3: o We must be able to safely meet your needs with the care you can get in CHOICES Group 3, This includes CHOICES home care up to $15,000 per year (not counting minor home modifications), other Medicaid services you qualify to receive from your BlueCare, services you can get through Medicare, private insurance or other funding sources, and unpaid care provided by family members and friends. If we decide your needs can t be met with the care you can get in Group 3, TennCare will see if you qualify to move to CHOICES Group 2 for more home care or CHOICES Group 1 for nursing home care. What if your needs can t be met at home or in the community (even with home care up to the cost of nursing home care) and you choose not to move to a nursing home? Then, you will be disenrolled from CHOICES. If you re disenrolled from CHOICES, you ll stay on TennCare as long as you still qualify for Medicaid. However, you ll no longer receive any long-term services and supports paid for by TennCare. You ll get a letter that says why your CHOICES is ending and how to appeal if you think it s a mistake. If the only way you qualify for Medicaid is because you receive long-term services and supports and you re disenrolled from CHOICES, your TennCare may end too. Before it does, you ll get a letter that says why. You ll get a chance to qualify in another one of the groups that Medicaid covers. Abuse, Neglect and Exploitation CHOICES members have the right to be free from abuse, neglect and exploitation. It s important that you understand how to identify abuse, neglect and exploitation and how to report it. Abuse can be Physical abuse; Emotional abuse; or Sexual abuse. It includes inflicting pain, injury, or mental anguish, unreasonable confinement, or other cruel treatment. Neglect can occur When an adult is unable to care for him/herself or to obtain needed care, placing his or her health or life at risk. This is self-neglect. 61

65 When the basic needs of a child or an adult who is dependent on others are not met by a caregiver, resulting in harm or risk of harm to health or safety. The neglect may be unintended, resulting from the caregiver's lack of ability to provide or arrange for the care or services the person requires. Neglect also may be due to the intentional failure of the caregiver to meet the person s needs. Exploitation can include Fraud or coercion; Forgery; or Unauthorized use of banking accounts or credit cards. Financial Exploitation occurs when a caregiver improperly uses funds intended for the care or use of an adult. These are funds paid to the adult or to the caregiver by a governmental agency. If you think you re a victim of abuse, neglect or exploitation or that any other CHOICES member is a victim of abuse, neglect or exploitation, please notify your Care Coordinator. All suspected incidents of abuse, neglect or exploitation of an adult should be reported to Adult Protective Services (APS) at All reports of abuse or neglect of a child should be reported to Child Protective Services (CPS) at or online at Long-Term Care Ombudsman The State s Long-Term Care Ombudsman program offers assistance to persons living in nursing homes or other community-based residential settings, like an assisted living or critical adult care home. A Long-Term Care Ombudsman does not work for the facility, the State, or BlueCare. This helps them to be fair and objective in resolving problems and concerns. The Long-Term Care Ombudsman in each area of the State can: Provide information about admission to and discharge from long-term services and supports facilities. Provide education about resident rights and responsibilities. Help residents and their families resolve questions or problems they have been unable to address on their own with the facility. Concerns can include things like: o Quality of care; o Resident rights; or o Admissions, transfers, and discharges To find out more about the Long-Term Care Ombudsman program, or to contact the Ombudsman in your area, call the Tennessee Commission on Aging and Disability for free at

66 Part 4: How the TennCare Program works for you What you pay for your health care Your Co-pays Preventive care is care that helps you stay well, like check ups, shots, pregnancy care, and childbirth. This kind of care is always free. You don t have co-pays for preventive care. More information about preventive care is in Part 2. For other care like hospital stays or sick child visits, you may have to pay part of the cost. Copays are what you pay for each health care service you get. Not everyone on TennCare has co-pays. Your BlueCare card will tell you if you have co-pays and what they are. Co-pays depend on: the kind of TennCare that you have (TennCare Medicaid or TennCare Standard), and sometimes on your family s monthly income before taxes, and how many people in your family live with you. Do you have other insurance that pays for your health care? Because you also have TennCare, you only pay the TennCare co-pay. Later in this handbook you ll learn more about how TennCare works with other insurance. Pregnant women do not have co-pays for medicine they get while they are pregnant. People getting hospice care do not have co-pays for prescription medicines they get for hospice care. If you are pregnant or you are getting hospice care, you must tell the pharmacist so you will not be charged your co-pay. You should only have to pay your co-pay for your care. You should not be billed for the rest of the cost of your care. If you are billed for the rest of the cost, you can appeal. See Part 5 of this handbook to find out what to do if you get a bill for your care. None of the doctors or health care providers in BlueCare can refuse to give you medically necessary services because you don t pay your co-pays. But, BlueCare and your providers can take steps to collect any co-pays you owe. Your health plan cards tell you if you have co-pays. Member ID Group No. VER: 5.1 (PCP) Primary Care Provider Effective Date Member DOB: Benefit Level: Copayments: Providers: File all claims with local BCBS Plan. Prior Authorization is required for certain services. Benefits will not be provided for unauthorized services or for non-emergency services provided by out-of-network providers. BlueCare Tennessee Claims Service Center 1 Cameron Hill Circle Suite 0002 Chattanooga, TN bluecare.bcbst.com Member Service: Network Provider Outside Tennessee: (BLUE) Provider Service: Prior Authorization: Advanced Radiological Imaging Auth: /7 Nurseline*: *Not BlueCross BlueShield products Members: Always show this card and tell your provider to check for prior authorization. Remembe r, you get your care from your care provider (PCP), listed on the front of this card, except in emergenc y. Call your PCP within 24 hours of emergency care. This card is for identification, not for proof of eligibility. 702 (05/13) 63

67 Your BlueCare card tells you if you have co-pays for doctors, specialists, hospital and ER visits. Your TennCare Pharmacy Plan card tells you if you have co-pays for prescription medicines. The following pages tell you more about TennCare co-pays and where to call if you have questions. 64

68 TennCare Co-pays Do you pay co-pays for a PCP, Specialist, ER visit, and hospital stay? Not sure? Check your BlueCare card or call the Tennessee Health Connection at PCP Prescription Emergency Room Hospital (general Specialist Member co-pay Use Stay doctor) co-pay (if not admitted) co-pay co-pay TennCare Medicaid children under 21 none none none none none TennCare Standard children under 21, below 100% federal poverty level* TennCare Standard children under age 21, from 100% to 199% federal poverty level* TennCare Standard children under age 21, at 200% and above federal poverty level* TennCare Medicaid adults 21 and older, who get long-term care that TennCare pays for TennCare adults 21 and older, who are in CHOICES Group 3 TennCare Medicaid adults 21 and older, who DO NOT get long-term care that TennCare pays for none none none none none $3 co-pay for Brand names; $1.50 co-pay for generics $3 for Brand names; $1.50 co-pay for generics $5 $5 $10 $5 $15 $20 $50 $100 none none none none none $3 for Brand names; $1.50 co-pay for generics $3 for Brand names; $1.50 co-pay for generics none none none none none none none none *To find out what percent of the federal poverty level (FPL) your household is, look at the income amounts online at: Do you have TennCare Medicaid? You can go to page 6. The next page is only important for members who have TennCare Standard. Do you have TennCare Standard? To find out what you must pay in co-pays for healthcare, look at your BlueCare card or call the Tennessee Health Connection at the phone numbers above. 65

69 If you have TennCare Standard, you will have a limit on the total amount of co-pays you will pay each quarter (every three months). You should have gotten a letter from TennCare that said how much your limit would be. The co-pays you pay for each child on TennCare Standard will be combined to help you reach your limit each quarter. Here s how TennCare counts the quarters in one year: 1 st quarter - January, February, and March 2 nd quarter - April, May, and June 3 rd quarter - July, August, and September 4 th quarter - October, November, and December Your family s co-pay limit every 3 months is based on the income you report to TennCare. This limit is the most you will pay in co-pays each quarter. Be sure to keep the receipts showing what you were charged in co-pays during the quarter. Keep them together in a safe place because you will need them later. Why? If you reach your out of pocket maximum in one quarter, you won t pay any more co-pays for that quarter. But you must tell TennCare when you ve reached your limit for the quarter. As soon as your receipts total your limit during one quarter, call the TennCare Solutions Unit for free at Tell them you ve reached your family s co-pay limit. They will ask you to send them copies of your receipts showing your total. Each receipt must show: The kind of care you got, the name of the person who got the care, the name of the doctor or other place that gave you the care, the date you got the care, and the amount you were charged for the care. Important! A cash register receipt, Explanation of Benefits (EOB), or credit card receipt may not show everything we need. After TennCare reviews your receipts, you ll get a letter that says you ve met your limit for that quarter. Once you get that letter, you won t have to pay any more co-pays for that quarter. When the new quarter starts, you ll pay your co-pays again. What if your receipts for the quarter total more than your limit? Call the TennCare Solutions Unit at Tell them you ve met your family s co-pay limit. If your income changes or your family size changes, your co-pays might change, too. You must report any changes in family size or income to TennCare by calling the Tennessee Health Connection as soon as possible. Do you have questions about co-pays or your quarterly limit? The Tennessee Health Connection can answer those questions too. Call them for free at

70 How TennCare works with other insurance and Medicare If you have other insurance, your TennCare works in a different way. TennCare and other insurance We discussed in Part 1 the difference between TennCare Medicaid and TennCare Standard. The kind of benefits you have, whether you must pay a co-pay, and whether you can have other insurance and still qualify for TennCare all depend on the kind of TennCare you have. In this section, we re going to discuss how TennCare works with other insurance. *Do you have Medicare? The next page tells you how TennCare works with Medicare. TennCare Medicaid and other insurance: Most people who have TennCare Medicaid can have other health insurance. This is how your TennCare Medicaid works if you have other insurance. Your other health insurance must pay first, before your TennCare. This is called your insurance. Your TennCare pays for covered services that your other health insurance does not cover. For example, if your other health insurance covers prescription medicines, you cannot use your TennCare for prescriptions. If you have other health insurance, you must tell: the place where you are getting health care so that they can bill the right insurance. the Tennessee Health Connection so that TennCare knows about your other health insurance. What if you get a bill for services that you think you should not have to pay? If you have other insurance besides TennCare, it could be because your different health insurance companies are not being billed correctly. Call us at for help. Co-pays If your insurance pays first for a TennCare covered service, you should only pay your TennCare co-pay. For example: your insurance has a $25 co-pay for a PCP office visit. But, you have TennCare Medicaid, and there is no TennCare co-pay for a PCP. What happens then? Your PCP should not charge you the co-pay but should file the claim for your visit with your insurance. TennCare Standard and other insurance: Most people who have TennCare Standard can t have other insurance or have access to group health insurance. Access to group health insurance means that you can get health insurance through an employer or some other group health plan. For TennCare Standard, it doesn t matter how much the other insurance costs, or what services it covers. What matters is if the other insurance has been offered to you, or is available to you. Remember, TennCare Standard is for children who are under age 19 who are losing their TennCare Medicaid. When it was time to see if they could keep TennCare Medicaid, they 67

71 weren t eligible. But, the TennCare Standard rules say that these children can move to TennCare Standard if they don t have access to group health insurance. Having access to other insurance, even Medicare, is not allowed for children who have TennCare Standard. Have you been in an accident? Sometimes when you are in an accident, there is someone else who should pay for your health care. This could be a car accident or an accident at work. You must let us know who should pay for your health care if you are in an accident. Call us for free at TennCare and Medicare counted the same as group health insurance. It is for people who are age 65 and older, and for some people of any age who Social Security says are disabled. People with end stage renal disease can have Medicare too. These are the different parts of Medicare: Part A is for hospital stays, skilled nursing facility care, home health care, and hospice care. Part B is for your doctor s services and outpatient care. Part D is for your prescription medicines. There are also other ways to have Medicare. These are called Medicare Health Plans (these plans are sometimes called Medicare Part C). These plans put all of the parts A, B, and D together for you in one plan. Medicare charges you for premiums, deductibles, and co-pays. If you can t pay for these, you can apply for a program called QMB. QMB (Qualified Medicare Beneficiary) pays for: Your Medicare premiums. The hospital deductible that Medicare doesn t pay. The part of each doctor bill that Medicare doesn t pay. You apply for QMB by calling the Tennessee Health Connection at If you have Medicare and get SSI, you already have QMB. You don t need to apply. To learn more about Medicare, call them at It s a free call. Another place that can help you with called SHIP (State Health Insurance Assistance Program). To get help with Medicare, you can call SHIP for free at If you have TennCare and Medicare, your TennCare works in a different way. Your your first () insurance. Hospitals, doctors and other health care providers will bill Medicare first. Your TennCare is your second (secondary) insurance. After your providers bill Medicare, they will also bill TennCare for your Medicare co-pays and deductibles. Remember, TennCare won t pay at all for prescriptions when adults have Medicare. Are you under age 21 with Medicare? Keep reading to find out when TennCare pays for your prescriptions). 68

72 Do you have TennCare Medicaid because you are enrolled in the Breast and/or Cervical Cancer (BCC) Program? Then you can t also have Medicare. If you become eligible for Medicare while you are enrolled in the BCC program, TennCare will send you a letter. It will say they must see if you re eligible for TennCare Medicaid another way. If you need health care that s not covered by Medicare but is covered by TennCare, go to a BlueCare provider for those TennCare covered services, so that TennCare will pay for them. For Medicare adults age 21 or older, TennCare does not pay for prescription medicines. Medicare Part D pays for your prescription medicines. For children under age 21 who have both TennCare and Medicare: o Medicare Part D pays for most of your prescription medicines. TennCare does not pay the co-pay for your Medicare prescriptions. o And, TennCare will pay for only those TennCare covered medicines that Medicare does not cover. 69

73 Part 5: Help for problems with your health care or TennCare Kinds of problems and what you can do You can have different kinds of problems with your health care. You can fix some problems just by making a phone call. If you have complaints or problems about your health care, call us at for help. Some problems may take more work to fix. Here are some examples of different kinds of problems and ways that you can fix them. Need a new TennCare card? If your card is lost or stolen, or if the information on your card is wrong, you can get a new one. For a new BlueCare card, call For a new Prescription Card, call TennCare s pharmacy help desk at You don t have to wait for your new card to get your care or medicine. Tell your doctor or the drug store that you have TennCare. Need to find a doctor or change your doctor? You can learn how to find a new doctor in Part 1 of this handbook. Are you changing because you are unhappy with the doctor you have? Please tell us. Call us at We want to make sure that you get good care. Need to make a complaint about your care? If you are not happy with the care that you are getting, call us at Tell us that you need to make a complaint. No one can do anything bad to you if you make a complaint. We want to help you get good care. Need help with a ride to your health care appointment? If you don t have a way to get to your health care visits, you may be able to get a ride from TennCare. Do you need help with a ride? Are you having problems setting up your ride or getting to your appointment on time? Call us at to tell us you need help. Need to change your health plan? If you want to change health plans because you re having problems getting health care, tell us. Call us at We ll help you fix the problem. You don t have to change health plans to get the care you need. Do you want to change health plans so you can see a doctor that takes that plan? Remember! You must make sure that all of your doctors take your new health plan. You ll only be able to see doctors that take your new plan. What if you have an OK from your health plan for care you haven t gotten? If you change plans and still need the care, you ll have to get a new OK from your new plan. Check these things before you decide to change health plans: 1. Does the doctor take the health plan you want to change to? 2. Is the health plan you want to change to taking new TennCare members? 70

74 There are two times when it s easy to change your health plan. 1. When you first get TennCare, you have 45 days to change your health plan. When you get TennCare, they send you a letter. That letter says how to change your health plan within the first 45 days. 2. Once a year during your open enrollment month. When you can change depends on where you live. Find Your County Below: Do you live in one of these West TN counties? Benton, Carroll, Chester, Crockett, Decatur, Dyer, Fayette, Gibson, Hardeman, Hardin, Haywood, Henderson, Henry, Lake, Lauderdale, Madison, McNairy, Obion, Shelby, Tipton, or Weakley If so, you can change your health plan during the month of March. Your new health plan assignment would begin May 1 st. Until then, we would continue to provide your care. Do you live in one of these Middle TN counties? Bedford, Cannon, Cheatham, Clay, Coffee, Cumberland, Davidson, Dekalb, Dickson, Fentress, Giles, Hickman, Houston, Humphreys, Jackson, Lawrence, Lewis, Lincoln, Macon, Marshall, Maury, Montgomery, Moore, Overton, Perry, Pickett, Putnam, Robertson, Rutherford, Smith, Stewart, Sumner, Trousdale, Van Buren, Warren, Wayne, White, Williamson, or Wilson If so, you can change your health plan during the month of May. Your new health plan assignment would begin July 1 st. Until then, we would continue to provide your care. Do you live in one of these East TN counties? Anderson, Bledsoe, Blount, Bradley, Campbell, Carter, Claiborne, Cocke, Franklin, Grainger, Greene, Grundy, Hamblen, Hamilton, Hancock, Hawkins, Jefferson, Johnson, Knox, Loudon, Marion, McMinn, Meigs, Monroe, Morgan, Polk, Rhea, Roane, Scott, Sequatchie, Sevier, Sullivan, Unicoi, Union, or Washington If so, you can change your health plan only during the month of July. Your new health plan assignment would begin September 1 st. Until then, we would continue to provide your care. Important! You have until the last day of your open enrollment month to ask to change your health plan. Other reasons that you can ask to change your health plan are if: You have family members in the health plan you want to change to Or, TennCare made a mistake by giving you a health plan that doesn t do business in the area where you live Or, you moved and your health plan doesn t do business in the area where you now live. You may be able to change your health plan if you have a hardship reason to change. But to meet hardship, all of these things must be true for you: 1. You have a medical condition that requires difficult, extensive, and ongoing care, and 2. Your specialist no longer takes your health plan, and 3. Your health plan doesn t have a specialist that can give you the care that you need, and 4. Your health plan can t work with your specialist to get you the care that you need, and 5. Your specialist takes the health plan you want to change to, and 6. The health plan you want to change to is taking new TennCare members. [Amendment to the TennCare Demonstration Project, approved June 15, 2012] **A specialist is a doctor who gives care for a certain illness or part of the body. One kind of specialist is a cardiologist who is a doctor that treats you for heart problems. Another is an 71

75 oncologist who is a doctor that treats you for cancer. There are many different kinds of specialists. To Ask To Change Your Health Plan you must tell TennCare: Your Social Security number. If you don t have that number, give your date of birth. Include the month, day and year. The name of the health plan you want. And, the reason you want to change health plans. Call The TennCare Solutions Unit (TSU) at Tell them you want to change your health plan. Or you can write to them on plain paper. If you write to the TennCare Solutions Unit (TSU), make sure you tell them: Your name (first, middle initial and last name) Your Social Security Number The name of the health plan listed above that you want to change to The name and social security number of anyone else in your family that also needs to change to this health plan Your daytime phone number and the best time to call. Then mail your request to: TennCare Solutions P.O. Box 820 Nashville, TN Or, you can fax your request to Need help getting your prescription medicines? Part 2 of this handbook tells you how TennCare works for prescription medicines. Do you need a doctor to prescribe your medicine for you? What if you need to find a doctor, or your doctor won t prescribe the medicine you need? Call us at Do you need an OK from TennCare to get your medicine? It s called a prior authorization or PA. If your medicine needs an OK, call your doctor. Ask your doctor to: Call the TennCare Pharmacy Program to get TennCare s OK for this medicine. Or, change your prescription to one that doesn t need an OK. What if your doctor doesn t ask for TennCare s OK or change your prescription? Then, you can ask TennCare to OK your medicine. Call What if your doctor asks for an OK and TennCare says no? You can ask your doctor to prescribe a different medicine that doesn t need an OK. Or, if you think TennCare made a mistake, you can appeal. You have 30 days after TennCare says no to appeal. For more information on how to appeal see Part 6 of this handbook. 72

76 Did you get a letter that said you asked TennCare to pay for more than 5 prescriptions or more than 2 brand name medicines this month? Call your doctor to see if you need all the medicine you re taking. What if he says you do? Then you may want to ask your doctor to help you pick the medicines that are most important. Or, you can ask your drug store to help you pick the medicines that cost most. Each month, get those filled first so TennCare will pay for them. You can ask the drug store or your doctor if your medicine is on the Exempt List. (That s TennCare s list of medicines that won t count against your prescription limit.) Even if you ve gotten 5 prescriptions or 2 brand name medicines in 1 month, you can still get medicines on that list. If you asked TennCare to pay for too many brand name medicines, ask your doctor to prescribe generic medicines. You can also talk to your doctor about the Over-the-Limit (or Attestation) List. After you ve reached your monthly limit (of 5 prescriptions or 2 brand name drugs), your doctor can get TennCare s OK to pay for drugs on this list. (Drug stores may call it the Prescriber Attestation list.) For more information on the Exempt List and the Over-the-Limit List, see Part 2 and Part 5 of this handbook. To get a current list of both, go to Or, if you think TennCare made a mistake counting your prescriptions this month, you can appeal. In your appeal, tell TennCare: 1. Your Social Security number. If you don t have that number, give your date of birth. Include the month, day and year. 2. The kind of medicine you are appealing about 3. And the reason you want to appeal that you think TennCare made a mistake counting your prescriptions this month. Tell us as much about the problem as you can. Be sure you include any mistake you think TennCare made. Send copies of any papers that you think may help us understand your problem. You can appeal by mail, fax, or telephone. For more information on how to file an appeal, see Part 6 of this handbook. Did the drug store say you don t have TennCare prescription coverage anymore? There are two ways this might happen: 1. For adults who have Medicare and TennCare, TennCare doesn t pay for prescriptions anymore. You must get your medicine through Medicare Part D. For help with Medicare Part D, call your Part D plan. Or, you can call Medicare at Sometimes your drug store can help you with Medicare Part D, too. 2. If you are an adult on TennCare Standard, your TennCare doesn t pay for prescriptions for you. To see if you can get other help with your medicine, call Cover RX at Did the drug store say that they can t fill your prescriptions because you don t have TennCare? Before your TennCare ends, you will get a letter in the mail. The letter will say why your TennCare is ending. It will also say how to appeal. But, if you move and don t tell TennCare, you may not get the letter. You may not find out that your TennCare ended until you go to the drug store. 73

77 Do you think TennCare made a mistake? Call the Tennessee Health Connection at In the Nashville area, call They can tell you if you have TennCare, or if it ended. If you think TennCare made a mistake, they can tell you if you still have time to appeal. Need help getting your health care services? Part 2 of this handbook tells you about the health care services that TennCare pays for. For problems about physical and/or behavioral health (mental health, alcohol or drug abuse) care, always call us at first. If you still can t get the care you need, you can call TennCare Solutions at Call Monday through Friday from 8:00 a.m. until 4:30 p.m. Central Time. But if you have an emergency, you can call anytime. Are you having trouble finding a doctor that takes BlueCare? Part 1 of this handbook tells you how to find a doctor. But if you moved and did not tell TennCare, you may have a problem finding a doctor where you live now. Your health plan may not do business in the area where you now live. Have you moved or are you planning to move? You must call the Tennessee Health Connection and tell them. Then, if you need a new health plan, TennCare will give you one. You will get a letter from TennCare that tells you the name of your new health plan. You will be able to find a doctor that takes your new health plan. Do you need an OK before TennCare will pay for your health care? It s called a prior authorization or PA. If your care needs an OK, call your doctor. Your doctor has to ask us for an OK. Did we say no when your doctor asked for an OK for your care? Call your doctor and/or behavioral health (mental health, alcohol or drug abuse) provider and tell him or her that we said no. If you or your doctor thinks we made a mistake, you can appeal. You have 30 days after your health plan says no to appeal. For information on Appeals, go to Part 6 of this handbook. Did you pay for health care that you think TennCare should pay for? Or, are you getting billed for health care that you think TennCare should pay for? Sometimes you might get a bill if the doctor doesn t know that you have TennCare. Every time you get care, you must: Tell the doctor or other place you get care that you have TennCare. Show them your TennCare card. If you ve gotten health care that you think TennCare should pay for, call us at If you re getting bills for the care, we can help you find out why. If you paid for the care, we ll see if we can pay you back. Or you can appeal. If you re getting bills, you have 30 days from when you get your first bill to appeal. If you paid for the care, you have 30 days after you pay to appeal. For information on Appeals, go to Part 6 of this handbook. 74

78 Ways your TennCare could end You can ask to end your TennCare. You must ask in writing. Send a letter to the Tennessee Health Connection that says you want to end your TennCare. Include your name, social security number and make sure you sign the letter. Important! If you don t sign your letter it will delay your request. You may have to send in another request with your signature. Do you want to end TennCare for other family members? Put their names and Social Security numbers in the letter too. Send your letter to: Tennessee Health Connection P.O. Box Nashville, TN Or fax it to: Other ways that your TennCare can end: If something changes for you and you don t meet the rules for TennCare anymore. If you let someone else use your TennCare card. If you don t follow the rules of BlueCare or TennCare, more than once. If you don t fill out redetermination papers for your TennCare when you are asked to. TennCare members must renew their TennCare each year. When it s time to see if you still qualify for TennCare, TennCare will send you a letter and redetermination pages in the mail. Before your TennCare ends, you will get a letter in the mail. The letter will tell you why your TennCare is ending. It also tells you how to file an appeal if you think they ve made a mistake. Do you need more help with health care? Or do you need more help with mental health care or drug or alcohol treatment? Or help with other TennCare problems? Call the TennCare Advocacy Program. Call them for free at

79 Part 6: TennCare Appeals If you are having problems with your healthcare or TennCare, you have the right to file an appeal. An appeal is one way to fix mistakes in TennCare. When you appeal, you re asking to tell a judge the mistake you think TennCare made. It s called a fair hearing. Your right to appeal and right to a fair hearing are explained more in Part 7 of this handbook. There are 2 different kinds of appeals: Administrative Appeals and Medical Appeals. Administrative Appeals are for problems like getting or keeping TennCare, disagreeing with the kind of TennCare you have, or if you think your income or co-pay amounts are wrong. Administrative appeals goes to the Eligibility Appeals Unit at the Tennessee Health Connection. Page 79 tells you more about filing an administrative appeal. Medical Appeals are for problems with your healthcare. For problems with health care, always call us at first. If you still can t get the care you need, you can file a medical appeal. Medical Appeals You have 30 days after you find out there s a problem to appeal. For care or medicine you still need, you have 30 days after TennCare or BlueCare says we won t pay for the care. For health care bills you think TennCare should pay, you have 30 days after you get your first bill. For care you paid for, you have 30 days after you pay for the care. Keeping Your Care During Your Appeal (Continuation of Benefits) If you are already getting care, you may be able to keep getting it during your appeal. To keep getting care during your appeal, all of these things must be true: 1. You must appeal by the date your care will stop or change (usually 2 or 10 days). 2. You must say in your appeal that you want to keep getting the care during the appeal. 3. The appeal must be for the kind and amount of care you ve been getting that has been stopped or changed. 4. Your appeal can t be for care you ve gotten that you want TennCare to pay for. 5. You must have a doctor s order for the care (if one is needed). 6. The care must be something that TennCare still covers. 7. You can t appeal to get more care than TennCare pays for. (For example, most adults have monthly limits on prescription medicines.) Important! What if you want to keep getting care during your appeal and you lose your appeal? You may have to pay TennCare back for the care you got during your appeal. 76

80 Do you and your doctor think you have an emergency? Usually, your appeal is decided within 90 days after you file it. But, if you have an emergency, you may not be able to wait 90 days. An emergency means if you don t get the care or medicine sooner than 90 days: You will be at risk of serious health problems or you may die. Or, it will cause serious problems with your heart, lungs, or other parts of your body. Or, you will need to go into the hospital. If one of those things is true for you, you can ask TennCare for an emergency appeal. There s a medical appeal page in Part 8 of this handbook. If your appeal is an emergency, you can have your doctor sign that page. What if your doctor doesn t sign a TennCare appeal form but you ask for an emergency appeal? Then, TennCare will ask your doctor if your appeal is an emergency. What if your doctor says your appeal isn t an emergency? Then, TennCare will decide your appeal within 90 days. Some kinds of appeals are never treated as an emergency: Care you ve already gotten (that you paid for or have gotten billed for) Care that s never covered by TennCare Care that helps you stay well (called preventive care) Braces for your teeth (orthodontia) How to file a Medical Appeal There are 2 ways to file a medical appeal: 1. Appeal by phone by calling the TennCare Solutions Unit at If you have a hearing or speech problem, you can call TennCare on a TTY/TDD machine. TennCare s TTY/TDD number is Call during business hours unless there is an emergency. Business hours are Monday through Friday from 8:00 a.m. until 4:30 p.m Central Time. But, if you have an emergency, you can call anytime. 2. Or, appeal in writing. You can use the medical appeal page in Part 8 of this handbook. If you give your OK, someone else like a friend or your doctor can fill the page out. To print an appeal page off the Internet, go to: If you need another medical appeal page or want TennCare to send you one, call TennCare Solutions at Or, you can write your appeal on plain paper. There are 2 ways you can file a medical appeal in writing. Pick one of the choices below: 1. Mail. You can mail an appeal page or a letter about your problem to: TennCare Solutions P.O. Box Nashville, TN Keep a copy of your appeal. Write down the date that you mailed it to TennCare. 2. Or Fax. You can fax your appeal page or letter for free to Keep the paper that shows your fax went through. 77

81 For all medical appeals, TennCare needs: Your name (the name of the person who wants to appeal about their care or medicine) Your Social Security number. If you don t have the SSN number, give your date of birth. Include the month, day and year. The address where you get your mail. The name of the person to call if TennCare has a question about your appeal (this can be you, or someone else). A daytime phone number for that person (this can be your phone number, or another person s phone number). What else does TennCare need to work your appeal? To get a fair hearing about health care problems, you must do both of these things: You must give TennCare the facts they need to work your appeal. And, you must tell TennCare the mistake you think we made. It must be something that, if you re right, means that TennCare will pay for this care. Depending on the reason you are filing a medical appeal, here are some other kinds of information you must tell TennCare: Are you appealing about care or medicine you still need? Tell TennCare: The kind of health care or medicine you are appealing about. And the reason you want to appeal. Tell TennCare as much about the problem as you can. Be sure you say what mistake you think TennCare made. Send copies of any papers that you think may help TennCare understand your problem. Are you appealing because you want to change health plans? Tell TennCare: The name of the health plan you want. And, the reason you want to change health plans. Are you appealing for care you ve already gotten that you think TennCare should pay for? Tell TennCare: The date you got the care or medicine you want TennCare to pay for. The name of the doctor or other place that gave you the care or medicine. (If you have it, include the address and phone number of the doctor or other place that gave you the care.) If you paid for the care or medicine, also give TennCare a copy of a receipt that proves you paid. Your receipt must show: o The kind of care you got that you want TennCare to pay for o And the name of the person who got the care o And the name of the doctor or other place that gave you the care o And the date you got the care o And the amount you paid for the care If you re getting a bill for the care or medicine, give TennCare a copy of a bill. Your bill must show: o The kind of care that you re being billed for o And the name of the person who got the care o And the name of the doctor or other place that gave you the care 78

82 o o And the date you got the care And the amount you are being billed What does TennCare do when you appeal about a health care problem? 1. When TennCare gets your appeal, they will send you a letter that says they got your appeal. If you asked to keep getting your care during your appeal, it will say if you can keep getting your care. If you asked for an emergency appeal, it will say if you can have an emergency appeal. 2. If TennCare needs more facts to work your appeal, you ll get a letter that says what facts they still need. You should give TennCare all of the facts that they ask for, as soon as possible. If you don t, your appeal may end. 3. TennCare must decide a regular appeal in 90 days. If you have an emergency appeal, they ll try to decide your appeal in 31 days. If they need more time to get medical records, they can take more time to finish your appeal. What if they don t finish your appeal on time? Then, TennCare must give you the care you asked for until your appeal is decided unless: The care you want is a kind of care that TennCare doesn t cover. Or, the care you want is not safe for you. Or, you don t have a doctor s order for the care you want. Or, you are the reason the decision is late. (You asked for more time.) 4. To decide your appeal, you may need a fair hearing. To get a fair hearing, you must say TennCare made a mistake that, if you re right, means you ll get the health care or service you re asking for. You may not get a fair hearing if you re asking for care or services that are not covered by TennCare. A fair hearing lets you tell a judge the mistake you think TennCare made. If TennCare says that you can have a fair hearing, you will get a letter that says when your hearing will be. TennCare will send your letter 21 days ahead of time (7 days if your appeal is an emergency). What happens at a fair hearing about health care problems? 1. Your hearing can be by phone or in person. The different people who may be at your hearing include: a judge who does not work for TennCare, a TennCare lawyer, a state witness (someone like a doctor or nurse from TennCare), and you. You can talk for yourself. Or, you can bring someone else, like a friend or a lawyer, to talk for you. 2. During the hearing, you get to tell the judge about the mistake you think TennCare made. You can give the judge facts and proof about your health and medical care. The judge will listen to everyone s side. 3. After the hearing, you will get a letter that tells you the judge s answer. What if the judge says you win your appeal? TennCare must agree that it s the right decision based on the facts of your case. Federal law says that a judge s decision is not final until TennCare OKs it. If TennCare overturns a judge s decision, we must tell you why in writing. 79

83 Remember, you can find out more about your Rights to a Fair Hearing, in Part 7 of this handbook. Administrative Appeals - Getting or keeping TennCare and other TennCare problems An appeal about TennCare problems other than health care is called an administrative appeal. An administrative appeal goes to the Eligibility Appeals Unit at the Tennessee Health Connection. An administrative appeal is used for TennCare problems like: You get a letter that says your TennCare will end, Or, your TennCare has ended but you didn t get a letter because you moved, Or, you think your TennCare co-pays are wrong, Or, you think TennCare gave you the wrong benefit package. If you have a problem like one of those listed above, call the Tennessee Health Connection at They will check to see if a mistake has been made. If they decide you re right, they will fix the problem. But if they say no, and you still think a mistake has been made in your case, you can appeal. How to file an Administrative Appeal There are 2 ways to file an administrative appeal: 1. Appeal by phone by calling the Tennessee Health Connection free at Or, appeal in writing. This appeal page is different from the page you use to file a medical appeal. You can get an appeal page from the Tennessee Health Connection. Or, you can write your appeal on plain paper. There are 2 ways you can file an administrative appeal in writing. Pick one of the choices below: 1. Mail. You can mail an appeal page or letter about your problem to: Tennessee Health Connection Eligibility Appeals Unit P.O. Box Nashville, TN Keep a copy of your appeal. Write down the date that you mailed it to TennCare. 2. Or Fax. You can fax your appeal page or letter for free to Keep the paper that shows your fax went through. If you write your appeal on plain paper, you must include: Your full name (first name, middle initial, last name) Your Social Security Number The names of other people who live with you with the same problem Your daytime phone number and the best time to call The specific mistake you think was made. Tell as much about the problem as you can. Send copies of any papers that show why you think the mistake was made. 80

84 Part 7: Your rights and responsibilities Your rights and responsibilities as a TennCare and BlueCare member You have the right to: Be treated with respect and in a dignified way. You have a right to privacy and to have your medical and financial information treated with privacy. Ask for and get information about BlueCare, its policies, its services, its caregivers, and members rights and duties. Ask for and get information about how BlueCare pays its providers, including any kind of bonus for care based on cost or quality. Ask for and get information about your medical records as the federal and state laws say. You can see your medical records, get copies of your medical records, and ask to correct your medical records if they are wrong. Get services without being treated in a different way because of race, color, birthplace, language, sex, age, religion, or disability. You have a right to file a complaint if you think you have been treated unfairly. If you complain or appeal, you have the right to keep getting care without fear of bad treatment from BlueCare, providers, or TennCare. Get care without fear of physical restraint or seclusion used for bullying, discipline, convenience or revenge. Make appeals or complaints about BlueCare or your care. Part 5 of this handbook tells you how. Make suggestions about your rights and responsibilities or how BlueCare works. Choose a PCP in the BlueCare network. You can turn down care from certain providers. Get medically necessary care that is right for you, when you need it. This includes getting emergency services, 24 hours a day, 7 days a week. Be told in an easy-to-understand way about your care and all of the different kinds of treatment that could work for you, no matter what they cost or even if they aren t covered. Help to make decisions about your health care. Make a living will or advance care plan and be told about Advance Medical Directives. Change health plans. If you are new to TennCare, you can change health plans once during the 45 days after you get TennCare. After that, you can ask to change health plans through an appeal process. There are certain reasons why you can change health plans. Part 5 and Part 6 of this handbook tells you more about changing health plans. Ask TennCare and BlueCare to look again at any mistake you think they make about getting on TennCare or keeping your TennCare or about getting your health care. End your TennCare at any time. Exercise any of these rights without changing the way BlueCare or its providers treat you. 80

85 Your rights to stay with BlueCare As a BlueCare member, you cannot be moved from BlueCare just because: Your health gets worse. You already have a medical problem. This is called a pre-existing condition. Your medical treatment is expensive. Of how you use your services. You have a behavioral health (mental health, alcohol or drugabuse) condition. Your special needs make you act in an uncooperative or disruptive way. The only reasons you can be moved from BlueCare are: If you change health plans. If you move out of the BlueCare area. If you let someone else use your ID cards, or if you use your TennCare to get medicines to sell. If you end your TennCare or your TennCare ends for other reasons. If you don t renew your TennCare when it is time, or if you don t give TennCare information they ask for when it is time to renew. If you don t let TennCare and BlueCare know that you moved, and they can t find you. If you lie to get or keep your TennCare. Upon your death. You have the responsibility to: Understand the information in your member handbook and other papers that we send you. Show your BlueCare ID card whenever you get health care. If you have other insurance, you must show that card too. Go to your PCP for all your medical care unless: o Your PCP sends you to a specialist for care. You must get a referral from your PCP to go to a specialist. o You are pregnant or getting well-woman checkups. o It is an emergency. Use providers who are in the BlueCare provider network. But, you can see anyone if it is an emergency. And, you can see anyone who has been approved with a referral. Let your PCP know when you have had to go to the Emergency Room. You (or someone for you) need to let your PCP know by 24 hours of when you got care at the ER. Give information to the BlueCare and to your health care providers so that they can care for you. 81

86 Follow instructions and rules that are in the handbook about your coverage and benefits. You must also follow instructions and rules from the people who are giving you health care. Help to make the decisions about your health care. Work with your PCP so that you understand your health problems. You must also work with your PCP to come up with a treatment plan that you both say will help you. Treat your health care giver with respect and dignity. Keep health care appointments and call the office to cancel if you can t keep your appointment. Not let anyone else use your BlueCare ID card and let us know if it is lost or stolen. Tell the Tennessee Health Connection of any changes like: o If you or a family member change your name, address, or phone number. o If you have a change in family size. o If you or a family member get a job, lose your job, or change jobs. o If you or a family member has other health insurance or can get other health insurance. Pay any co-pays you need to pay. Let us know if you have another insurance company that should pay your medical care. The other insurance company could be insurance like auto, home, or worker s compensation. 82

87 Other rights and responsibilities as a TennCare and BlueCare member Your right to fair treatment We do not allow unfair treatment in TennCare or BlueCare. No one is treated in a different way because of race, language, religion, birthplace, disability, sex, color, or age. In TennCare, unfair treatment can mean things like: They didn t let you take part in the same things as other people. You didn t get the help you needed to get your care. You didn t get the care that you needed. You have the right to make a complaint if you think you are not getting fair treatment. By law, no one can get back at you for making a complaint. If your complaint is about either physical health care and/or behavioral health (mental health, alcohol or drug abuse) care, you can call us at , or write to us at: Office of Non-Discrimination Bureau of TennCare 310 Great Circle Rd. Nashville, TN If you write to us, be sure to include: your name your address your daytime phone number, and your Social Security number. Tell us as much as you can about the problem. You can write on a plain piece of paper or you can use the Unfair Treatment Complaint Page in Part 8 of this handbook. Here are some other places you can call or write if you think you have been treated unfairly: Agency Phone Numbers Address TennCare toll-free For TTY dial 711 and ask for fax Office of Non-Discrimination Bureau of TennCare 310 Great Circle Rd. Nashville, TN State of Tennessee toll free fax Director Title VI Compliance Program Tennessee Human Rights Commission 312 Rosa Parks Blvd., 23 rd Floor Nashville, TN U.S. Dept of Health and Human Services, Region IV Office toll free TDD/TTY 83 U.S. DHHS/Region IV Office of Civil Rights 61 Forsyth St. SW 3 rd floor Suite 3B70 Atlanta, GA 30303

88 U.S. Dept. of Health and Human Services, Washington, D.C. Office toll free TDD/TTY U.S. DHHS/Office of Civil Rights 200 Independence Ave. SW, Room 506F Washington, D.C Your Right to Appeal Health Care Problems in TennCare In TennCare, you get your health care through a TennCare health plan. You have rights when an action is taken that keeps you from getting health care when you need it. 1. You have the right to get an answer from your health plan when you or your doctor asks for care. For some kinds of care, your doctor must get your health plan s OK before TennCare will pay for it. It s called a prior authorization or PA. What if your doctor asks your health plan to OK care for you? Your health plan must decide in 14 days. If you can t wait 14 days for the care you need, you can ask them to decide sooner. Or, you can appeal before the end of the 14 days. If they take more than 21 days to decide, they must give you the care you asked for unless: The care you want is a kind of care that TennCare doesn t cover. Or, the care you want is not safe for you. Or, you don t have a doctor s order for the care you want. 2. You have the right to get a letter from your TennCare plan if: Your TennCare health plan says no when you or your doctors ask for health care. Or, you have to wait too long to get health care. Or, your TennCare health plan stops or changes your health care. The letter must say why you can t get the care and what you can do about it. If your health plan decides to change care you re getting, you should get a letter at least 10 days before it happens. If they decide to change your hospital care, you should get a letter 2 business days before it happens. What if your doctor decides to change care you re getting? For these kinds of care, you should get a letter 2 business days before it happens: Behavioral health (mental health, alcohol or drug abuse) treatment for a priority member which includes a child with Serious Emotional Disturbance (SED) or an adult with Severe and Persistent Mental Illness (SPMI) Behavioral health (mental health, alcohol or drug abuse) treatment in a hospital or other place where you must stay to get the care (inpatient psychiatric or residential services) Care for a long-term health problem when your health plan can t give you the next kind of care you need for that problem Home health services If your health plan or doctor doesn t send your letter in time, they can t change your care. 3. You have the right to appeal if: 84

89 TennCare says no when you or your doctors ask for health care. Or, TennCare stops or changes your health care. Or, you have to wait too long to get health care. Or, you have health care bills you think TennCare should have paid for, but didn t. You only have 30 days to appeal after you find out that there is a problem. Someone who has the legal right to act for you can also file an appeal for you. 4. You have the right to a fair hearing about your appeal if you think TennCare made a mistake. To get a fair hearing, you must say TennCare made a mistake that, if you re right, means you ll get the health care or service you re asking for. You may not get a fair hearing if you re asking for care or services that are not covered by TennCare. A fair hearing lets you tell a judge the mistake you think TennCare made. What if a judge says you win your appeal? TennCare must agree that it s the right decision based on the facts of your case. If TennCare does not agree, we can overturn the judge s decision. Federal law gives TennCare this right. If TennCare overturns a judge s decision, we must tell you why in writing. If TennCare doesn t overturn the judge s decision, TennCare has 5 business days to do what the judge ordered. 5. If you have an emergency, you have the right to get a decision about your appeal within 31 days (but sometimes up to 45 days). An emergency means if you don t get the care sooner than 90 days: You will be at risk of serious health problems OR you may die. Or, it will cause serious problems with your heart, lungs, or other parts of your body. Or, you will need to go into the hospital. If you think you have an emergency, you can ask TennCare for an emergency appeal. Your appeal may go faster if your doctor signs your appeal saying that it is an emergency. What if your doctor doesn t sign your appeal, but you ask for an emergency appeal? TennCare will ask your doctor if your appeal is an emergency. If your doctor says it s not an emergency, TennCare will decide your appeal within 90 days. Some kinds of care are never treated as an emergency. To get a list of those kinds of care, ask TennCare. Usually, you have the right to get a decision about your emergency appeal within 31 days. If TennCare needs more time to get medical records, we can take up to 45 days to finish your emergency appeal. What if TennCare doesn t finish your appeal on time? Then, TennCare must give you the care you asked for until your appeal is decided unless: The care you want is a kind of care that TennCare doesn t cover. (Care that TennCare doesn t cover is never an emergency anyway.) Or, the care you want is not safe for you. Or, you don t have a doctor s order for the care you want. Or, you are the reason the decision is late. (You asked for more time.) 6. You have the right to get a decision about your appeal within 90 days if it s 85

90 not an emergency. What if TennCare doesn t finish your appeal on time? Then, TennCare must give you the care you asked for until your appeal is decided unless: The care you want is a kind of care that TennCare doesn t cover. Or, the care you want is not safe for you. Or, you don t have a doctor s order for the care you want. Or, you are the reason the decision is late. (You asked for more time.) 7. If you are already getting care, you may have the right to keep getting it during the appeal. To keep getting care during your appeal, all of these things must be true: You must appeal by the date your care will stop or change (usually 2 or 10 days). You must say in your appeal that you want to keep getting the care during the appeal. Your appeal can t be for more care or for a different kind of care than you ve been getting. (You can only ask to keep care you ve been getting during your appeal.) Your appeal must be for care you still need. What if you ve already gotten all the care and want TennCare to pay for it? You won t get more during your appeal. If you needed a doctor s order to get the care, you ll still need a doctor s order to keep getting it during your appeal. The care must be something that TennCare still covers. Your appeal can t be for more of the care than TennCare pays for. (Most adults have monthly limits on prescription medicines.) What if you keep getting care during your appeal and you lose your appeal? You may have to pay TennCare back for that care that you got during your appeal. Your Right to a Fair Hearing in TennCare You have the right to: 1. Have a fair hearing with a judge if you think TennCare made a mistake. Remember, you may not get a fair hearing if you re asking for care or services that are not covered by TennCare. 2. Know about the hearing 3 weeks ahead of time (1 week for an emergency appeal). 3. Be at the hearing in person or by phone. 4. Speak for yourself at the hearing. 5. Have someone help you at the hearing. 6. See the facts TennCare and your health plan used to decide about your care. You can see this information before the hearing. 7. Look at your medical records and use them as proof. 8. Give the judge other proof that shows why TennCare made the wrong decision. 9. Bring witnesses with you. 10. Have the judge order your witnesses to come. 11. Question witnesses for TennCare. 86

91 12. Ask to have a doctor who does not work for TennCare say what medical care you need. You do not have to pay for this. 13. Get a written decision in 90 days (sooner if it s an emergency appeal). 14. When a decision is late, get the medical care until the decision is made unless: The care you want is a kind of care that TennCare doesn t cover. Or, the care you want is not safe for you. Or, you don t have a doctor s order for the care you want. Or, you are the reason the decision is late. (You asked for more time.) 15. If TennCare overturns a judge s decision, have TennCare tell you why in writing. 87

92 TennCare Notice of Privacy Practices Revised effective September 23, 2013 This notice describes how medical information about you may be used and disclosed. It also tells you how you can get access to this information. Please review it carefully. Your TennCare is not changing. You don t have to do anything. These papers tell you how we keep your health facts private. The federal government tells us we must give you these papers. These papers tell you: 1. the kinds of health information we have 2. how we share it 3. who we share it with 4. what to do if you don t want your health information shared with certain people 5. and your rights about your health information. Your Health Information is Private We know you value the privacy of your health information or Protected Health Information (PHI). We call this kind of information your health facts or PHI. PHI is any information used to identify you and to record your health and medical history. Federal law says we must follow privacy rules to keep your PHI private. This law started on April 14, Everyone who works with us and for us must also follow these privacy rules. 1. The kinds of PHI we have When you applied for TennCare you told us certain facts about you. Like your name, where you live, and how much money you make. We also have health facts like: A list of the health services and treatments you get Notes or records from you doctor, drug store, hospital, or other health care providers Lists of the medicine you take now or have taken before Results from x-rays and lab tests Genetic information ( genetics are family traits like hair color or eye color. It can also be health conditions that you have in common with your blood relatives.) 2. How we share your PHI We can only share your PHI as the law lets us. The privacy rules let us share PHI for your care, to pay your health claims, and run our program. We share your PHI to: Show you have TennCare and to help you get the health care you need. Pay your health plan and health care providers. Check how TennCare benefits are being used and to check for insurance fraud. 3. Who can we share your PHI with? With you. We can help you schedule check ups and send you news about health services. Other people involved in your care, like family members or caregivers. You can ask us not to share your PHI with certain people. And we can share your PHI with everyone who works with TennCare like: Health providers like doctors, nurses, hospitals, and clinics. Your health plan or other companies that have contracts with TennCare. People helping with appeals if you file a TennCare appeal. Your appeal may be in person or over the phone. Sometimes other people may be with you in your appeal hearing. Federal, state, or local government agencies providing or checking on health care. 88

93 Who else can we share your PHI with? The privacy rules also say we can share PHI with people like: Coroners, funeral homes, or provides who work with services like organ transplants. Medical researchers. They must keep your PHI private. Public health agencies to update their records for births, deaths, or to track diseases. The court when the law says we must or when we re ordered to. The police or for other legal reasons. We can report abuse or neglect. Other agencies like for military or veterans activities, national security, jails. We can also share your PHI if we take out the PHI that tells who you are. But, we can t share your PHI with everyone. And we can t share your genetic information to make decisions about your eligibility for TennCare. Sometimes we ll need your OK in writing before we can share your PHI. We ll ask you to sign a paper giving us your OK if we need to use or share (disclose) any of the following information: 1. To use or share notes a therapist takes during therapy sessions (these are called psychotherapy notes); 2. To use or share PHI with companies who will use the information to try to get other people s business (for marketing purposes); and 3. Sharing (disclosures) PHI with someone else for money. Can you take back your OK? Yes. You can take back your OK anytime. But you must tell us in writing. We can t take back the PHI we ve already shared. 4. What if you don t want all of your PHI shared? You must ask us in writing not to share certain facts about your health. You must tell us the PHI you don t want shared and who you don t want us to share your PHI with. There are other times when we won t share your PHI if you ask us. We ll say OK if we can. But we might not say OK if you are a minor child or if we re allowed to share the PHI by law. If we can t say OK, we ll send you a letter that says why. 5. Your health information Rights You can take back your OK anytime but you must tell us in writing. We can t take back the PHI we ve already shared. You can see and get copies of your records in paper or if we have them in electronic form, you can get them electronically. You must ask in writing to do so. You may have to pay money for the cost of copying and mailing your copies. If we can t give you the PHI you want, we ll send you a letter that says why. You can talk to TennCare about how we share your PHI. And you have the right to: Ask us in writing not to share certain facts about your health. Ask us to not show your PHI in certain records. Ask us to change PHI that s wrong. You must ask in writing and tell us why we need to change it. If we can t make the change, we ll send a letter that says why. Ask us in writing to contact you in a different way or in a different place. If writing or talking to you in place puts you in danger, tell us. Ask us in writing for a list of who we ve shared your PHI with. 89

94 The list will say who got your health facts for the six (6) years before the date of your request. But, it won t list the times we ve shared when you ve given us your OK. The privacy rules give other times that won t be on the list. Like when we use PHI: to help you get health care, or to help with payment for your care, or to run our program, or to give to law enforcement if we re required by law to do so. TennCare s Responsibility to you TennCare safeguards your PHI to protect its privacy and security. If your PHI is not safeguarded and it gets out, we have to notify you and federal authorities. But we only have to notify you: If the kind of PHI that got out would identify who you are (like your name, your Social Security Number, or your date of birth) or your treatment records, Depending on who the person was that used or saw your PHI, If anyone actually used or saw your PHI, What we did to lessen the risk that your PHI was used. Requests ask us in writing Your requests must be in writing. Be sure you tell us what you re asking us to do. Write your name and TennCare ID number or Social Security Number on your letter. Send your letter to: TennCare Privacy Officer Bureau of TennCare 310 Great Circle Road Nashville, TN Keep a copy of the letter for your records. Do you have questions? Do you need help making your request? Call the Tennessee Health Connection at for free. Changes in this Notice TennCare s policies and procedures about requests may change without notice. We ll use the policies and procedures we have in place when you make your request. Federal privacy rules and TennCare privacy practices may also change. If important changes are made, we ll send you the changes in writing. We have the right to apply the changes to all the health facts we have. Or only to new health facts we get. Changes in this notice start September 23, 2013 and apply to all health facts we have. If you need a new copy or want to check for changes, go to Or call the Tennessee Health Connection for free. Questions or Complaints We do not allow unfair treatment in TennCare. No one is treated in a different way because of race, color, birthplace, language, sex, age, or disability. You will not be punished if you complain or ask for help. Do you have questions? Do you think your privacy rights have been violated? Do you think you have been treated unfairly? Call the Tennessee Health Connection at for free. Or you can write to: TennCare Privacy Officer OR U.S. Department of Health and Human Services Bureau of TennCare Office for Civil Rights 310 Great Circle Rd. Atlanta Federal Center, Suite 3 B70 Nashville, TN Forsyth St. SW Atlanta, GA

95 Your responsibility to report fraud and abuse Most TennCare members and providers are honest. But even a few dishonest people can hurt the TennCare program. People who lie on purpose to get TennCare may be fined or sent to jail. If you find out about a case of fraud and abuse in the TennCare program, you must tell us about it. But you don t have to tell us your name. Fraud and abuse for TennCare members can be things like: Lying about facts to get or keep TennCare. Hiding any facts so that you can get or keep TennCare. Letting someone else use your TennCare ID card. Selling or giving your prescription medicines to anyone else. Fraud and abuse for TennCare providers can be things like: Billing TennCare for services that were never given. Billing TennCare twice for the same service. To tell us about fraud and abuse, call BlueCare for free at Here are some other places that you can call or write to tell us about fraud and abuse: Agency Phone Address Office of Inspector General (OIG) Tennessee Bureau of Investigation (TBI) toll-free toll-free Office of Inspector General P.O. Box Nashville, TN TBI Medicaid Fraud Control Unit 901 R.S. Glass Blvd. Nashville, TN You can also tell us about fraud and abuse online. Go to Then click on Report Fraud on the left hand side of the page. 91

96 Part 8: Healthcare Papers You May Need 92

97 Primary Care Provider (PCP) Change Request Fill this out and mail to: BlueCare Claims Service Center 1 Cameron Hill Circle, Suite 0035 Chattanooga, TN When you choose a PCP, we will send you a new ID card. You can begin seeing your new PCP on the effective date on your new card. Member Information: Your Name: Last First MI Your Street Address: City: State: Zip Code: Your ID number: Your Birth Date: / / Month Day Year Your Telephone Number: ( ) Area code Number PCP 1 st Choice: Name of PCP you want: Last First Address: Telephone Number: ( ) Area code Number Provider ID number (listed in the Provider Directory): PCP 2 nd Choice: Name of PCP you want: Last First Address: Telephone Number: ( ) Area code Number Provider ID number (listed in the Provider Directory): 93

98 You have a right to fair treatment. If you think you have been treated unfairly, this page tells you who to contact. We do not allow unfair treatment in TennCare. State and Federal laws protect you from unfair treatment. No one can treat you in a different way because of your: Race Disability Religion Birthplace Color Age Sex Language In TennCare, unfair treatment could mean many things. It could mean someone treated you differently because of one of the things listed above. For example: Maybe they didn t let you take part in the same things as other people. Maybe you did not get the help you needed to get health care. Maybe you did not get the health care that you needed. Do you think you have been treated unfairly? You may contact any of the places listed below for help. You also have the right to file a complaint. By law, no one can get back at you for filing a complaint. This is who you can contact if you are treated unfairly under TennCare. Is your problem with your Physical or behavioral health care? Then call your health plan. Dental care? Then call your dental plan. The number for each plan is listed in your Member Handbook. Ask to speak with the Nondiscrimination Compliance Coordinator. Bureau of TennCare You can call the Office of Non-discrimination at: (615) You can call the Office of Non-discrimination toll free at: You can write to: Office of Non-discrimination Bureau of TennCare 310 Great Circle Rd. Nashville, TN hcfa.fairtreatment@tn.gov Fax: (615) For TTY/TDD dial 711 and ask for U.S. Department of Health & Human Services Office for Civil Rights You can call for free You can write to: Director - Office for Civil Rights U.S. Department of Human Services 200 Independence Ave., SW Room 506 F Washington, DC TTY/TDD: Toll Free U.S. Department of Health & Human Services- Region IV Office for Civil Rights You can call: (404) You can write to: U.S. DHHS / Region IV Office for Civil Rights 61 Forsyth Street, SW - 3rd Floor, Suite 3B70 Atlanta, Georgia Fax: (404) THRC Tennessee Title VI Compliance Program You can call (615) You can write to: Director 312 Rosa Parks Blvd., 23 rd Floor Nashville, TN Fax: (615)

99 Usted tiene el derecho a que lo traten de una manera justa. Si piensa que ha sido tratado injustamente, esta página le dice con quien comunicarse. TennCare no permite el trato injusto. Las leyes federales y estatales protegen a su familia contra el tratamiento injusto. Nadie lo puede tratar de una manera diferente debido a su: Raza Sexo Color de la piel Religión Lugar de nacimiento Discapacidad Idioma Edad En TennCare, ser tratado de una manera injusta podría significar muchas cosas: podría significar que alguien lo trató de una manera diferente debido a una de las cosas indicadas arriba. Por ejemplo: Quizás no lo dejaron participar en las mismas cosas que a otra gente. Quizás no le dieron la ayuda que necesitaba para obtener servicios de atención de la salud. Quizás usted no recibió la atención de la salud que necesitaba. Cree que lo han tratado injustamente? Usted se puede comunicar uno de los lugares indicados abajo para obtener ayuda. Usted también tiene el derecho a reclamar. Por ley, nadie se puede vengar porque usted reclame. Estos son los contactos para comunicarse si lo tratan injustamente en TennCare. Está relacionado su problema con: Atención física o psiquiátrica (mental)? Entonces llame a su plan de seguro médico. La atención de su salud dental? Entonces llame a su plan de seguro dental. El número de cada plan se indica en su Manual para miembros. Pida hablar con el coordinador de cumplimiento con la no discriminación. Bureau of TennCare Puede llamar a la Oficina de No Discriminación al (615) Puede llamar a la Oficina de No Discriminación gratis al Puede enviarle una carta a: Office of Non-Discrimination Bureau of TennCare 310 Great Circle Road Nashville, TN hcfa.fairtreatment@tn.gov Fax: (615) Para TTY/TDD, marque el 711 y pida el U.S. Department of Health & Human Services Office for Civil Rights Puede llamar gratis al Puede enviarle una carta a: Director - Office for Civil Rights U.S. Department of Human Services 200 Independence Ave., SW Room 506 F Washington, DC TTY/TDD: llamada gratuita U.S. Department of Health & Human Services Region IV Office for Civil Rights Puede llamar al: (404) Puede enviarle una carta a: U.S. DHHS / Region IV Office for Civil Rights 61 Forsyth Street, SW - 3rd Floor, Suite 3B70 Atlanta, GA Fax: (404) THRC-Tennessee Title VI Compliance Program Puede llamar gratis al (615) Puede enviarle una carta a: Director 312 Rosa Parks Blvd., 23 rd Floor Nashville, TN Fax: (615)

100 Unfair Treatment Complaint Federal law says that unfair treatment is not allowed. No one can be treated in a different way because of race, color, birthplace, religion, language, sex, age, or disability. If you feel that you have been treated unfairly for any of these reasons, you have the right to complain. We do not allow unfair treatment in TennCare. We need the following facts so we can look into your complaint. If you need help to fill out this page, let us know. 1. Are you filing this complaint for yourself? Yes No If yes, go to question number 2. If no, tell us your name: Give us a phone number where we can reach you:( ) 2. Write your answers to the questions in the box below: Name of Person You Feel Was Treated Unfairly Last Name: First Name: Middle Name or Initial: Date of Birth / / Month Day Year Full Mailing Address: Social Security Number: - - Include street name, street number, route, apartment number, lot number, PO Box, etc. City: State: Zip: Day Phone ( ) 3. Who do you think treated this person unfairly? Night Phone ( ) Name: Address: City, State, and Zip Code: Phone Number ( ) - or - ( ) 4. Give us facts about the unfair treatment. Check the box or boxes that you think were the reason for the unfair treatment. 96

101 Race Color Birthplace Language Spoken Religion Disability Age Sex On what date did the unfair treatment take place? Do you think it has happened other times? Yes No If yes, how many other times? Have you complained about this problem before and tried to have it stopped? Yes No If yes, who have you talked to about it? What date did you talk to them about it? Have you filed this complaint with another federal, state, or local agency? Yes No Have you filed this complaint with any federal or state court? Yes No If yes, check all that apply: Federal agency Federal court State agency State court Local agency If yes, tell us the name of the contact person at the agency/court where you filed the complaint: Name: Agency/Court Name: Address: City, State, Zip Code: Phone Number: ( ) 5. In your own words, tell us what happened. You can attach more pages if needed. Sign your name below. Attach any other information that you think will be helpful. Sign here. X: Date: Print your name: Date: If you filled out this page for someone else, sign here.x [Note: if you helped someone file this complaint, you don t have to sign.] Print your name: Date: 97

102 Mail these pages to: BlueCare Non-discrimination Compliance Coordinator 1 Cameron Hill Chattanooga, TN If you have questions, please call for help. For TTY/TDD, please call: 711 and ask for To get help in another language, call us at or call one of these numbers: Language Toll Free Number Arabic Bosnian Kurdish-Badinani Kurdish-Sorani Somali Spanish Vietnamese TennCare does not allow unfair treatment based on race, color, language spoken, sex, sexual orientation, religion, handicap/disability or age. 98

103 Member Handbook 2013 Having problems getting health care or medicine in TennCare? Need help filing a medical appeal? Call for free. Use this page only to file a TennCare Medical Appeal. Fill out both pages. These are facts we must have to work your appeal. If you don t tell us all the facts we need, we may not be able to decide your appeal. You may not get a fair hearing. Need help understanding what facts we need? Call us for free at If you call, we can also take your appeal by phone. 1. Who is the person that wants to appeal? Full name Date of birth / / Social Security Number - - Or number on their TennCare card Current mailing address City State Zip Code The name of the person we should call if we have questions about this appeal: A daytime phone number for that person ( ) - 2. Who filled out this form? If not the person that wants to appeal, tell us your name. Are you a: Parent, relative, or friend Advocate or attorney Doctor or health care provider 3. What is the appeal for? (Place an X beside the right answer below. Want to change health plans. (Fill out Part A on page 2.) Need care or medicine. (Fill out Part B on page 2.) Have bills or paid for care or medicine you think TennCare should pay. (Fill out Part C on page 2.) 4. Do you think you have an emergency? Usually, your appeal is decided within 90 days after you file it. But, if you have an emergency, you may not be able to wait 90 days. An emergency means if you don t get the care or medicine sooner than 90 days: You will be at risk of serious health problems or you may die. Or, it will cause serious problems with your heart, lungs, or other parts of your body. Or, you will need to go into the hospital. Do you STILL think you have an emergency? If so, you can ask TennCare for an emergency appeal. Your appeal may go faster if your doctor signs below saying that this appeal is an emergency. What if your doctor doesn t sign below, but you ask for an emergency appeal? TennCare will ask your doctor if your appeal is an emergency. If your doctor says it s not an emergency, TennCare will decide your appeal within 90 days. Some kinds of care are never treated as an emergency. To get a list of those kinds of care, ask TennCare. If YOU want to ask TennCare for an EMERGENCY APPEAL, check this box. Your DOCTOR can read and sign here to ask TennCare for an emergency appeal. I certify under penalty of perjury that I am the treating physician of the patient on behalf of whom this medical appeal is filed and that this appeal is an emergency. If this patient is required to wait 90 days for this care, s/he is at risk of serious health problems or death, severe impairment of bodily organs or parts, or hospitalization. I understand that any intentional act on my part to provide false information is considered an act of fraud under the State s TennCare Program & Title XIX of the Social Security Act. Physician Signature: Date: Tennessee License Number: 99

104 Member Handbook Tell us why you want to appeal this problem. Include any mistake you think TennCare made. And, send copies of any papers that you think may help us understand your problem. To see which Part(s) you should fill out below, look at number 3 on page 1. Part A. Want to change health plans. Name of health plan you want Part B. Need care or medicine. What kind - be specific What s the problem? Can t get the care or medicine at all. Can t get as much of the care or medicine as I need. The care or medicine is being cut or stopped. Waiting too long to get the care or medicine. Did your doctor prescribe the care or medicine? Yes No If yes, doctor s name Have you asked your health plan for this care or medicine? Yes No If yes, when? What did they say? Did you get a letter about this problem? Yes No If yes, the date of the letter Who was the letter from? Are you getting this care or medicine from TennCare now? Yes No Do you want to see if you can keep getting it during your appeal? Yes No Does your doctor say you still need it? Yes No If yes, doctor s name If you keep getting care or medicine during your appeal and you lose, you may have to pay TennCare back. Part C. Bills for care or medicine you think TennCare should pay for The date you got the care or medicine Name of doctor, drug store, or other place that gave you the care or medicine Their phone number ( ) - Their address Did you pay for the care or medicine and want to be paid back? Yes No If yes, you must send a copy of a receipt that proves you paid for the care or medicine. If you didn t pay, are you getting a bill? Yes No If yes, and you think TennCare should pay, you must send a copy of a bill. Tell us the date you first got a bill (if you know). How to file your medical appeal Make a copy of the completed pages to keep. Then, mail these pages and other facts to: TennCare Solutions P.O. Box 593 Nashville, TN Or, fax it (toll-free) to Keep a copy of the page that shows your fax went through. To appeal by phone, call for free. Have speech or hearing problems? Call our TTY/TDD line for free at We do not allow unfair treatment in TennCare. No one is treated in a different way because of race, color, birthplace, language, sex, age, religion, disability. If you think you ve been treated unfairly, call the Tennessee Health Connection for free at

105 Advance Directives Advance Directives are your written wishes about what you want to happen, if you get too sick to be able to say. Living Will or Advance Care Plan Machines and medicine can keep people alive when they otherwise might die. Doctors used to decide how long someone should be kept alive. Under the Tennessee Right to Natural Death Act, you can make your own choice. You can decide if you want to be kept alive by machines and for how long by filling out a Living Will. In 2004, Tennessee law changed the Living Will to Advance Care Plan. Either one is ok to use. A Living Will or Advance Care Plan needs to be filled out while you can still think for yourself. These papers tell your friends and family what you want to happen to you, if you get too sick to be able to say. Your papers have to be signed, and either witnessed or notarized. If your papers are witnessed, your papers need to be signed in front of two people who will be your witnesses. These people: One of these people cannot be related to you by blood or marriage. Cannot receive anything you own after you die. Cannot be your doctor or any of the staff who work in the place where you get health care. Once they are signed by everyone, it is your rule. It stays like this unless you change your mind. Tennessee Durable Power of Attorney for Health Care or Appointment of Health Care Agent The Durable Power of Attorney for Health Care paper lets you name another person to make medical decisions for you. In 2004, Tennessee law changed the Durable Power of Attorney for Health Care to Appointment of Health Care Agent. Either one is ok to use. This person can only make decisions if you are too sick to make your own. He or she can say your wishes for you if you can t speak for yourself. Your illness can be temporary. These papers have to be signed, and either witnessed or notarized. Once the papers are signed by everyone, it is your rule. It stays like this unless you change your mind. These papers will only be used if you get too sick to able to say what you want to happen. As long as you can still think for yourself, you can decide about your health care yourself. If you fill out these papers, make 3 copies: Give 1 copy to your PCP to put in your medical file. Give 1 copy to the person who will make a medical decision for you. Keep a copy with you to put with your important papers. 101

106 Member Handbook 2013 Important! You do not have to fill out these papers. It is your choice. You may want to talk to a lawyer or friend before you fill out these papers. 102

107 Member Handbook

108 Member Handbook

109 Member Handbook 2013 Part 9: More information TENNderCARE: TennCare s Early Periodic Screening, Diagnosis and Treatment Under EPSDT (Early Periodic Screening, Diagnosis and Treatment) for children under 21 we cover: Regular, periodic visits to the doctor to see if the child is developing normally and to see if he or she has any physical or behavioral health (mental health, alcohol or drug abuse) problems, dental, or other conditions. This is called screening and needs to happen according to the American Academy of Pediatrics (AAP) Periodic Schedule. For example: Children from birth through age 2 have the right to get 11 screens ; Children from age 3 through age 11 have the right to get 7 screens Children from age 12 through age 20 have the right to get, 9 screens * In addition, a child has a right to get a screening whenever the child is referred to a doctor by someone such as a teacher who notices a change in the child s health or behavior. Screenings include the following: o A comprehensive health and development history; and o A comprehensive unclothed physical exam; and o Appropriate immunizations; and o Appropriate vision and hearing tests; and o Appropriate laboratory tests; and o Dental services; and o Health education You also get other services in addition to screening services:. Treatment, including rehabilitation, for any health problems (physical, mental or developmental) or other conditions discovered during a screening. You can also get scheduling assistance for services. Regular visits to a dentist for checkups and treatment; Regular, periodic tests of the child s hearing and eyesight. Includes treatment of any problems with hearing and eyesight; Immunizations (shots) for diphtheria, tetanus, pertussis, polio, measles, mumps, rubella (MMR), HIB, influenza, Hepatitis A and B vaccines, varicella, Rotavirus, Human papillomavirus (HPV) and Meningitis, pneumococcal; and Routine lab tests. (Note a test for lead in the blood and sickle cell anemia will be done if the child is in a situation that might put him or her at risk for either or both of these things) 105

110 Member Handbook 2013 If your child has a high level of lead in his or her blood, lead investigations will be done. If you think that your child has been around things that have a high lead content, such as old paint, tell your doctor; and Health education; and Transportation and scheduling assistance: If you can t get your child to his or her health visits, you may be able to get a ride. Transportation and scheduling help is available when you have to go far away from home to get to and from care. Transportation help for a child includes costs for travel, cost of meals, and a place to stay. It may also include someone to go with the child if necessary. Call your health plan to schedule your TENNderCare appointment and transportation; and. Other necessary health care, diagnostic services, treatment and other measures necessary to correct improve defects or prevent defects from worsening; if your child has physical and mental illnesses and conditions that are found in the screening process, they are treated. Basic health education for child and parents is part of the preventive services TennCare gives you. Co-payments are not required for preventive services. 106

111 Member Handbook 2013 TENNderCARE: Children and Teen Immunization Schedule 107